HomeMy WebLinkAbout2025-00065026 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0039.83241
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00065026 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -1
850 N STATE ST Elgin00:22
® ❑ RELATED ❑Y ®N 10 04 2025 ®AM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
Q83 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 C)
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Levin. Russell. R. 0 7 /
yr 13-UNDER CARRIAGE 10 i ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 4 ❑Y ®N SYSTEM❑UNK VEH. ATCRASHD 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it 6 i. 4 COM VEH 0 Ea 2 C)
F. FIRST CONTACT 12 7 _� ,-05 •II Yes.See Sidebar U1 0
Z ELGIN IL 60123 0 1 0 KITTY63 IL 2025 REAR
TELEPHONE
NJ D 0 GRAY State Farm ❑Y ®N U2 m
19 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Levin. Kathryn. M. 2196158-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NMV 0 KDV ❑DV
'1 9 6 5 Jeep(after 19681�rokee 2001 00-NONE 1 t2 DUE TO CRASH D ® U2 C 2
o yr — 13-UNDER CARRIAGE
c,�2 FIRE
c ig
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 6 .t. 4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 6 O7 ,�_Q)OS •IfYes.See Sidebar C
ELGIN IL 60123 C 1 0 BD46789 IL 2026 REAR 0 Si)
M
IL D 0 1J4FF48S21L621207 Farmers Insurance ❑Y JN RDEF .73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same G01-281 1 058-04 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 10,04 l2025 00 22 ®❑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 C)
0 2 03 17 ) ! ❑PM ❑Construction *
Z 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Levin. Russell. R. 11-601-Ax 471-000563 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
35
t 2 ❑ ARREST NAME AM
1 r ❑❑PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
471-Evans, Lakysha 501 331-Ziegler 11 , 18,2025 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
8507N_Tetete?8L Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
` ` --I -' r INDICATE NORTH combination):or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
l�q�i - . - . transporting employees in the course of their employment(example:employee X
y a van type
or co
i. i..__4._._J , •- 1 42lsuosedordrter- esllnatedtotransehrtbetweeicle or n9a d15enger rpassen rs,includingthedriver.
} } i- for direct compensation(example:large van used for specific purpose):or 0
i , •
co-,
.0 t i i .. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
a placarding(example:placards will be displayed on the vehicle).
m
2#
— — — — — CARRIER NAME
Z
._ ADDRESS 0
f c..arierrare. D
CITY/STATE/ZIP n0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I . I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
:I. -,r- - Not To SoaJ!J - USDOT NO. ILCC NO. C
XI
Source of above z
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ Unknown C
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
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 3 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