HomeMy WebLinkAbout2025-00067699 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111111111111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003998116
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00067699 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mFOX LN Elgin 02:35
® ❑ RELATED ®Y 0 N 10 16 2025 ❑AM YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W HOLM ES RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 C)
FRObff TOWED U1 O
NAME(LAST,FIRST,M) y- mo yr
Williams. Bradley.J. Chevrolet Equinox 2023 00-NONE „ 12 0DUE TO CRASH ❑ VI
13-UNDER CARRIAGE 101 2 FIRE 0NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 76•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i 4 COM VEH 0 j$J 1 0
F. FIRST CONTACT I 7_•�-; _;__5 *II Yes.See Sidebar U1
Z SOUTH ELGIN IL 60177 0 1 0 EW23989 IL 2026 Is
TELEPHONE
IL D 0 3G NAXH EG8PL128348 Farmers ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 541966471 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES O Nov 0 N v ❑DV
/1 9 9 7 Nissan Versa 2009 00-NONE „ ` �i,0 DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE I, FIRE ❑ ® U2
c
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y gi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I .i, 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 8 O7 j_, _s •IfYes.See Sidebar C
ELGIN IL 60123 B 1 0 FM99413 IL 2026 I Si)0
IL D 0 3N1 BC11 E59L422753 First Chicago Insurance C ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X
Elgin Fire Same ILS119159900 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 07 / F 2 5 C 1 0
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/ / #OCCS >
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 10,16 /2025 02 35 ®AM 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 C)
2 23 99 / / ❑PM ❑Construction >F
O 4
R 3 ❑ $I CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Williams. Bradley.J. 11-1204-B 482000591 / / El PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
El AM
f 2 El ARREST NAME 10/16 /2025 02 35 ®PM El Unknown work zone type U1 3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
482-Flentye.Jeremy 502 11 , 41 /025 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.
A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r -- r••--, , IFbIma7Rd N - 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }--_.r-_--; o } combination):or —I
INDICATE NORTH P1
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
, 1 r r t- (example:shuttle or charter bus):or 0
` I- --I-- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
__.� Unit 2 / . 4. Is used or designated to transport between 9 and 15 passengers,including cC/t
-- / '' - } } } g po passen rs,indudi the driver,
j/^ for direct compensation(example:large van used for specific purpose):or O
L L--_-a..... l ' J t. I. I ._ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
i-1 placarding(example:placards will be displayed on the vehicle).
a FmnLr, D
/a CARRIER NAME Z
/"':'7L' ADDRESS 0J,,/ V
i
n
CITY/STATE/ZIP
Not To Scale
1 MOTOR CARR.ID ❑ Interstate ElIntrastate 5
I I I I ❑ Not in Comm./Govt. Not in Comm./Other
� ""Y" 1 USDOT NO. ILCC NO. m
XI
Source of above z
. 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
Gray Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 1 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE