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HomeMy WebLinkAbout2025-00066969 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 01 0 �� 01000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03991290 u, 1 U2 1 1 1 U1 4 U2 U, 1 U2 U, 1 U2 4 7 U1 3 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑g501-g1,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00066969 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED PRIVATE ®Y 0 N 10 13 2025El AM ❑YES ®NO U1 —< LONGCOMMON PKWY)ROUTE 20 Elgin mo /day/yr 02:20 ❑PM FLOW CONDITION m • ®20 ®!MI N E S © LONGCOMMON PKWYI ROUTE 20 COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18: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 0 1 FOR DAMAGEDAREA(S) FROM TOWED U1 0 NAME(LAST,FIRST,M) Smith.Shon. D. mo 0 / 13-UNDERCARRIAGE i FIRE ❑ ® 10 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m M 2 6 ❑Y ® n is-OTHER SYSTEM❑UNK VEH. AT CRASH 99-UNKNOWN 9 t6•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_i� s �i 4 COM VEH 0 Ea 2 O ~ ELGIN N I L 60124 0 1 0 FIRST CONTACT 1 7 ; __5 *Ilves.See Sidebar U1 ZEP55488 IL 2026 E TELEPHONE IL D JA4J4VA85RZ048820 State Farm ❑Y ®N U2 rM in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Smith.Shon. D. 1852655sfp13 1 1- 5 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 XI 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 12 _ C Ti 13-UNDER CARRIAGE 10 I 2 FIRE 0 ❑ U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0 0 Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 - POINT OF 8-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7 =1:-5 COM•I sVSee •SidebarEH ❑ 0 C CO F` pE--, C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 20 10!13 l2025 02 20 ®❑PM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 40 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 19 28 ! ! ❑PM ❑Construction >F t Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 —a, ARREST NAME Smith.Shon. D. 11-601 747932 ! r El PM SLMT o N 0 iffi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility AM 50 t 2 0 ARREST NAME Smith.Shen. D. 11-501-A-2 747933 ! ! 0 PM 0 Unknown work zone type U1 n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 1545-VanEycke. Brier 801 331-Ziegler 11 , 14,2025 09 00 IDPM ®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 -I INDICATE NORTH -1 ' - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or L A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O C } } 1.- transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a._ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 ' L.._-a____. - / - l. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 'D rn 0 placarding(example:placards will be displayed on the vehicle). XI� ; 2:. I . I Z CARRIER NAME Z Not TO Scale I , ' ADDRESS 0 T. CITY/STATE/ZIP 0 g ��..,,-��. - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I 1 !. -• r ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 -"--------1 - USDOT NO. ILCC NO. C m XI Source of above z . 0 Yes 0 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 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 Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage . 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