HomeMy WebLinkAbout2025-00061807 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 10 Sheets 01111101111
011011001 0110 11111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003968563
u, 1 U2 1 1 1 U116 uz 1 U, 1 1_12 U, 1 U2 1 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00061807 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 5 -n
2739 ALFT LN El In09:05
® ❑ RELATED ❑Y ®N 09 20 2025 ®AM ID YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 cn
❑ FT/MI NESW &RUN
Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS O
Qg3 DRIVER t] PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 O
Bacon. Brent.A. 0 8 /
yr 13-UNDER CARRIAGE 10l !�. 2 FIRE ❑
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 rn
M 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 76•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i! S i.r.4 COM VEH 0 Ea 5 0Z Genoa IL 60135 0 1 0 FIRST CONTACT 5 7 ; _(9 •lives.See Sidebar Ut 0
118066SB IL 2025 REAR
TELEPHONE
IL Other 7 4DRBUC8N8MB129401 Collective Liability ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Genoa-Kingston Commu CLICAL2025 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 33 (,0j
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV
yr 12 _ C
0 13-UNDER CARRIAGE 101 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 0 ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `0istraglon Value 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I4 COM VEH D ® Ut CO
1.* 1 l
FIRST CONTACT 8 7 B .s • C
EY56866 IL 2025 REARIfYes.See Sidebar 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FMJK1 M84REB10081 American Select ❑Y 0 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Phillips.Jennifer WNP169669J BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 7 03 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 09/20 /2025 09 05 ®❑AM in a Work Zone? ®N DIRP co
1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 28 99 / / ❑PM• 0 Construction *
1
Z3 o xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
o ® 11 1 ARREST NAME Bacon. Brent.A. 11-601-Ax 1529-000502 / ! El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
t 2 ❑ ARREST NAME AM
7 / / pM 0 Unknown work zone type 35
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
1529 Audi red.Jonathan sot / / ❑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•---, , Li
A CMV is defined as any motor vehicle used to transport passengers or property and: Z1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
r r --I -' r INDICATE NORTH combination):or —I® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} `1 r rr (example:shuttle or charter bus):or 03. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} -A- -•i ` } } } transporting employees In the course of their empbgeyment(example:employeey a van type
< <.___a____; ` . 1 I �sedordrter- �llnatedtotransehrtbetweeicle or n9and15r r):orC
Alft?Ln. • } } g po fic purp including[he driver, totmR2 � � for direct compensation(example:large van used fors cific pur e):orO
coo an a�:: D
' L.__-a..... - _ __ _ i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
_ rn
placarding(example:placards will be displayed on the vehicle). �
���� CARRIER NAMENot Z
ADDRESS 0
w
2739?AN1"?Ln. CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I . 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
1— --- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 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 ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
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
Yellow White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE