HomeMy WebLinkAbout2025-00065122 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00065122 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
® ❑ RELATED ' V 0 N 10 04 2025 ❑AM ❑YES ®NO U1 -<
TOASTMASTER DR Elgin12:29
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W CONGDON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 99 Cl)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg)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 2 n
0 4 !
yr 13-UNDER CARRIAGE NI
10 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 ❑Y ®Nn is-OTHER
SYSTEM
❑UNK VEH. AT CRASHD 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S i L S i COM VEH 0 Ea 1 O
F. FIRST CONTACT 1 7_;—_;__5 *rrves.See Sidebar U1
V Z St Charles IL 60174 0 1 0 AQ62079 IL 2025 REAR
TELEPHONE
IL D 0 3VW2K7AJXDM421257 ALLSTATE ❑Y ®N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 962735206 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused El El 2 0
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED F4 PEDAL 0 EWES 0 Iluy 0 i v 0 DV
/1 yr 9 9 3 Huffy 00-NONE 'o,I t2 c,�2 DUE TO CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
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M 5 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;,- S j1:,-4 COM VEH If Yes.See Sidebar❑ ® U1 W
FIRST CONTACT 00 7 =5 •
Z ELGIN IL 60120 B 1 0 NIA REAR N
IL D 0 NONE ❑Y ❑N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
3 49 2 NONE BAc E
HOSPITAL(TAKEN TO) INCIDENT RESPONDER IF'Y' OWNER STREET,CITY STATE,ZIP 996 ARefused ❑Y El U1 =
(UNIT) (SEAT) (DOB) (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
N 1 ® 13 1 10,04 /2025 12 29 ®PM in a Work Zone? ®N DIRP co
I r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
Si 2 ❑ 26 28 10/04 )2025 12 29 ®pm ❑Construction *
R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
-a, ARREST NAME LAY.SOMPHONE 11-903 374001340 10!04/2025 12 35 lgi pM SLMT
1 El 11 1 El
0 CITATIONS ISSUED PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME Utility
r 2 El ARREST NAME 10 r 04 l2025 12 29 ®PM El Unknown work zone type U1 0 AM
25
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
374 Rizzu o. Michael 201 11 +04,2025 01 30 ®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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
TOASTMASIER?OR BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I - } (example:shuttle or charter bus):or 0
X
3. Is designed to carry15 or fewer passengers and operated a contract career O
}} } transporting employee �In the course of their employment(example:employee
co
L I or transporter sed or usually
designated to transport betweeicle or n 9 and 15 passengers,including the driver. C
"N"' Not To Scale ] I. } } for direct compenation(examp large van used for speific purose):or
L t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I placarding(example:placards will be displayed on the vehicle). XI
1 'I
CARRIER NAME Z
CONGOON?AIE
ADDRESS 01 C
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 UnknownT.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El 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'; ❑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
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE El NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE