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HomeMy WebLinkAbout2025-00066984 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III H IIII OUI 01100111011 I0100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003991297- u, 1 U21 2 4 1 u, 2 U2 1 u, 1 u2 1 u, 1 U2 1 2 15 u1 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 202512025-00066984 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ' V 0 N 10 13 2025 ®AM El YES ®NO U1 -< ST CHARLES ST Elgin07:26 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EDUCE 0 uuv 0 ICY 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROf4T TOWED U1 I� Lloyd. Ernest. E. 0 7 / yr 13-UNDER CARRIAGE ©,I �:: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 2 m M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 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�a 4 COM VEH 0 0 3 0 F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 EE98-DD IL 2026 REAR TELEPHONE IL D 0 WDBUF87XX9B370177 Foremost Insurance ❑Y Il N U2 nni 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 734120602-0 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ❑ N 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES O ntry 0 Ncv ❑DV CIRCLE NUMBER(S) U1 /1 994 Chrysler 300 2017 00-NONE 11_ 12 t2 _, DUETOCRASH ❑ 2 0 13-UNDER CARRIAGE 101 E FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0�I S I,_4 COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 8 l:!�_1_O ._5 •If Yes.See Sidebar ELGIN IL 60123 0 1 0 FF70249 IL 2026aR 9 N IL D 0 2C3CCAGG6HH527002 First Chicago Insurance ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X 99 9 Same I LS 1015900-02 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 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 10!13 l2025 07 26 ®❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T o" 2 ❑ 2 18 / ! ❑PM, ❑Construction X Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 - u a, ARREST NAME Lloyd. Ernest. E. 11-901-A W1543000261 ! ! El PM SLMT 1 ® 11 4 ❑CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility PENDING o AM u, 30 t 2 ❑ ARREST NAME 10!13 /2025 07 26 j PM ❑Unknown work zone type n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 1543-Sturgeon. Kyle 400 - ! r 0 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 r I 1. Hasor more than pounds(example:truck or truck trailer 1. Has a weight rating10 000 � -< INDICATE NORTH combination): -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } (example:shuttle or charter bus):or 0 .2 I0 r 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O -- Se? I } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w Dwlpht?St . 4. Is used or designated to transport between 9 and 15 passengers,including rCjt }--- ----+ - } } } g po passen rs,includi the driver, A for direct compensation(example:large van used for specific purpose):or it O L____a____. ram. I i _ L L I t 5. Is any vehicle used to transport any hazardous material(HAZMAT) •p - - - I unit 1 - - placarding(example:placards will be displayed on the vehicle). .Zm1 CARRIER NAME Z I _ ADDRESS 0 V) g 4r1 "1 r I � _ MOTOR CARR.ID 0 Interstate El Intrastate Not To Scale J ❑ Not in Comm./Govt. ❑ Not in Comm./Other ----------1 - USDOT NO. ILCC NO. C m XI Source of above z . If Yes,Name on placard 0 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 T. 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black White 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE