HomeMy WebLinkAbout2025-00066755 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 001 fll 111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003989997"
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INVESTIGATING AGENCY DAMAGE TO ANY El g500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑ssol-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00066755 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED PRIVATE ❑Y ®N 10 11 2025DAM ❑YES IX]NO U1
RT20 WB Elgin mo /day/yr 10:03 ®PM FLOW CONDITION ITT
•'Z COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
Ie- T/0) NOS W South State St WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
0 3 /
Toyota Corolla 2017 00-NONE Q. O 1:7T DUE TO CRASH ❑
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13-UNDER CARRIAGE ) 2 FIRE 0 NIC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 M
M 2 4 ❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 t6•TIDP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 ii,4 COM VEH 0 j$J 1 O
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7_; __5 *Il ves,See Sidebar Ut
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TELEPHONE
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B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12AU001573102 1 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
0 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 iiuv 0 i v 0 DV
yr 12 _ C
13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C
c lij SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR O
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 0 -
POINT OF 6-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 L`'_5 C•IO es See SidebarEH
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESPElYD❑N NDER U1 Z
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
1 3 08 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 20 1 10!11 /2025 10 03 ®PM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 99 99
t / / ❑PM• El Construction
Z3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME / / ❑PM '
o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
o N El AM SECTION CITATION NO. ROAD CLEARANCE TIME ❑
t 2 ElARREST NAME 10/1 1 /2025 10 20 0 PM El Unknown work zone type
, U1 45
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y
2 3 0 - ❑AM Workers present?
1554-Wagener.Vincent 700 ! / ❑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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
el BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}----------1 _ Not To Scats I - } } } transportingemployees in the course of their employment
pbyment(example:employee
MEOW
y a van type
< ...I. ® 1 1 transporter sedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,includingthedrrver,
® • } } for direct compensation(example:large van used for specific purpose):or
L L____a____.I — — — — — — —6 — — _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
M
—I
CARRIER NAME Z
ADDRESS
w
CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_..-- ----; - USDOT NO. ILCC NO. rn
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 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
to
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE