HomeMy WebLinkAbout2025-00065674 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003984969
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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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00065674 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
® ❑ RELATED ❑Y ®N 10 07 2025 E�IAM ❑YES ®NO U1
N MCLEAN BLVD Elgin06:45
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
0 !MI N E S W West Highland AveCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
g Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 7 !
yr
Pettit. Ryan.J. Ford Escape 2017 00-NONE 11 . 12
, DUE TOCRASH ® ❑
13-UNDER CARRIAGE FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0 U2 4 <<Tl
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASIN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 �i COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar U1
Z EU56781 IL 2025 E
TELEPHONE
IL C 1 FMCU9G D6H U E49214 First Chicago ®Y ❑N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
ce
Same ILS1064844-00 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 DV
!1 9 9 5 Nissan Maxima 2016 00-NONE „ 12 _, DUE TO CRASH ❑ 2 x
0 Yr
®13-UNDER CARRIAGE FIRE ❑ El U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF
T CONTACT 1 O C).1] 6 l`5 C•OM
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IL D 1 N4AA6AP2GC406389 State Farm ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Same 1603939-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,71 ,025 06 48 ®❑PM 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 �
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2 ❑ 10 20 ) ! ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Pettit. Ryan.J. 11-708 W3400159 r ! El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
o N 0 AM 30
t 2 El ARREST NAME Pettit. Ryan.J. 3-707 340000158 r r PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
340-Phillips. Kathryn 600 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.
0 IF MORE THAN ONE CMV IS INLVED,USE SR 1050A
ADDITIONAL UNITVOS FORMS.
r ----r••--, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r1. Has a weight
i- `'----------; ,NI i�, ,—!!+ - INDICATE NORTH combination):or rating more than 10,000 pounds{example:truck or truckrtrailer
:gI I fi. 'c I I N i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ ci �' t - (example:shuttle or charter bus):or
-p I I 3. Is designed t carry 15 or fewer passen ers and o rated a contract carrier 0
1
--___------1 .Q Not To Sca/e • } } } transport) employees in the course of their employment
ngpbyment(example:employee 1
Ipr I• r I transporter-usually a van type vehicle or passenger car):or 03
C
L L.___a__ - I. } } 1 •4. Is used or designated to transport between 9 and 1passengers,including the driver,
Ifor direct compensation(example:large van used fors cific purose):or
F-----h---1
�.1 - t t t 1 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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- y. -- placarding(example:placards will be displayed on the vehicle). XI
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Hf AND?` 2#
® CARRIER NAME Z
1 ADDRESS 0
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CITY/STATE/ZIP g
_ i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I r 09 I ❑ Not in Comm./Govt. Not in Comm./Other
;_...Y. ._. USDOT NO. ILCC NO. m
I 1 XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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 Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE