HomeMy WebLinkAbout2025-00060520 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011001 011111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003966683
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00060520 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 09 14 2025 ❑AM ❑YES ®NO U1 -<
N STATE ST Elgin mo /day/yr 05:23 ®PM FLOW CONDITION M
1 O(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 to
® C.'J/MI N E O W I-90 WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FROM TOWED U1 Q
WAS. BAN I PAL.A. Toyota Camry 2025 00-NONE ,, t2 , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE i FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 Ea U2 4 M
M 2 SYTM 4 ❑Y ®$NE DUNK VEH. 0 AT CRASH 99-UUNKNOWN THER 9 6 TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Dail a �'.4 COM VEH 0 Ea 1 0
~ ELGIN I N I L 60123 B 1 0 FIRST CONTACT 9 7 . -_5 *II Yes.See&debar U1
Z FC86749 IL 2026 E
TELEPHONE
IL D 0 4T1DBADK7S0004115 GEICO INSURANCE ❑Y ®N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 6183-91-21-84 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y El 2 0
m E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NI/V 0 Ncv 0 DV
/2 0 0 4 General Motortii6'a1� 1998 00-NONE ,. ' t2 DUE TO CRASH rg ❑ 2 x
.. Yr 13-UNDER CARRIAGE I FIRE ❑ ® U2
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 x
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracuon Value 9 0
POINT OF s i1 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5 lf,_
FIRST CONTACT 1 7�- -5 *If Yes.See Sidebar
= MCHENRY IL 60051 0 1 0 FH89539 IL 2026 I0
IL D 0 1 G KCS13W2W2511370 STATE FARM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3652906SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 1 05 /
UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 91 ,41 /025 05 23 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 99 91 /41 /025 05 27 ®pM ElConstruction
R O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM ❑Maintenance U2
-a, ARREST NAME )WAS. BAN I PAL.A. 11-708 1551000209 9/ /41 /025 05 32 ®pM CITATIONS ISSUED PENDING SLMT
1 ® 11 1 ❑ Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME Ely
T 2 El ARREST NAME 9/ /4/ /025 06 23 ®PM 0 Unknown work zone type ID AM U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1551-Dede.Joseph 501 10 / 14/2025 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 -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed totranff passengers including the driver ortmorethan15 C
- r r r (example:shuttle or charter bus):or 0
L A J I U I / 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or
L L.___a____� ^ r 4. Is used ordesinatedtotrans rtbetween9and15passengers,includingthedriver. O
I I 1 } } } for direct compensation(example:large van used for speific purose):or
_ I I Not To Scale i < . < L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
lin° :. : :. :__ __:.
XI
CARRIER NAME Z
I - ADDRESS O
I I w
r I CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--- ----4. - USDOT NO. ILCC NO. m
Xl
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO La DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE