HomeMy WebLinkAbout2025-00058901 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00058901 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mVILLA ST Elgin06:29
® ❑ RELATED ' ' 0 N 09 07 2025 ❑AM ❑YES IX]NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W S LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NW ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 C)
FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q
NAME(LAST,FIRST,M) g mo
!1 9 9 1 Subaru Outback 2025 00-NONE ,, • 12 , DUE TO CRASH 0 13-UNDER CARRIAGE FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0U2 OO r<If
M I 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_i L 6 �i 4 COM VEH 0 0 1 0
F. FIRST CONTACT 1 7 ;—_;__5 *Irves.See Sidebar U1
Z Chesterton IN 46304 0 1 0 553 EJ N IN 2025 REAR
TELEPHONE
IL Other 0 4S4BTACC1 S3224564 Progressive ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Christopher. Nuss.A. 996979865 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nu v 0 K V 0 DV
'1 9 yr 0 Honda Accord 1999 00-NONE O Qi-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( l 2 FIRE 0 ® U2 C
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0is/rectos Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7�REARS •IfYes.See Sidebar C
= ELGIN
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M IL 60120 0 1 0
IL D 0 State Farm ❑Y 123J N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2307350-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOS DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 09,07 l2025 06 29 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
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0
2 0 2 28 ) ! ❑PM• ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME Washington. Dexter. L. 11-601 1561-000074 / ! El PM SLMT
o u 1 ® 11 4 igiCITATIONS ISSUED 0 PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• • Ely
f 2 0 ARREST NAME Washington. Dexter. L. 11-709-A 1561-000073 09107 12025 07 05 ®PM El Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1561-Sarovic• Mirko 401 10 1 06,2025 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }-- -'-- --' 1 N,� - r INDICATE NORTH combination):or -I
Not To Scale _
1 BY ARROWi. 2 Is used or designed to transport more than 15 passengers including the driver C
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(example:shuttle or charter bus):or n
3. Is designed to car 15 or fewer ssfen ers and o rated a contract carrier O
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} } } transporting employees In the course�of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L L____a____.: +: _-I___� _ t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
- - - �<-ram - - - 1 placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
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re ,,. I ADDRESS 0CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. 0 Yes 0 No ❑ Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
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Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Green
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE