HomeMy WebLinkAbout2025-00067898 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003998056
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 8
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 20255120255-00067898 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 �I
1565 GIFFORD RD El In11:08
® ❑ RELATED ❑Y ®N 10 17 2025 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
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COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW CO
❑ FT!MI N E S W Cook 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
Qg3 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)
1 0 FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
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International I uhrcCab 2020 00-NONE 11' t DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) PADAL. H I LARY.A. mo yr
13-UNDER CARRIAGE to i 12 2 FIRE 0NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M I 2 4 ❑Y ® is-OTHER
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TIDP 3 `Distraction Value 9 ALGN =
r POINT OF ICITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR $ s li 4 COM VEH 0 j$J 1 0
F. FIRST CONTACT 6 7_;L-Q_-5 *IIYes.SeeSidebar U1
Z Crystal Lake IL 60120 0 1 0 M225045 IL 2026 ,
TELEPHONE
IL A 7 3HAEJTAN7LL878848 CHARTER OAK FIRE ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 CITY OF ELGIN 8109160P901 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
yr 12 _ 71
o 13-UNDER CARRIAGE 10.i t, 2 FIRE ❑ 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ ❑ SPDR C)
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 0 -
POINT OF 8 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y —d:-5 COM•I sVSee •Sidebar❑ ❑ C
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
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❑YO❑N NDER U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 5 Com Ed utility pole 10,17 /2025 11 08 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
;, 2 ❑ 31 5 350 SECOND ST ELGIN IL 60123 30 99
! ! ❑PM ❑Construction *
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Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM '
o N 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit25
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SLMT
t 2 ❑ ARREST NAME AM
7 ! 1 ❑❑pM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
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2 3 0 ❑AM Workers present? ❑
374 Rizzu o. Michael 401 ! / ❑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
OIFFORD?ROAO ADDITIONAL UNITS FORMS.
r ----r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
e Not To Scale -<
1. Has a weight rating more than 10,000 pounds{example:truck or truck/trailer
` ` ' ' r INDICATE NORTH combination):or p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including y}-----;----; b - } } } g po passen rs,indudi the driver,
for direct compensation(example:large van used for specific purpose):or O
<____A____� UNIT _ i. < i. ,_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m
placarding(example:placards will be displayed on the vehicle). ;p
-.— — —DI
to CARRIER NAME Z
4'
ADDRESS 'n
V)
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------.; - USDOT NO. ILCC NO. rn
XI
Source of above z
.
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
co
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. Z
White
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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE