HomeMy WebLinkAbout2025-00067927 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X 399:955
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00067927 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 71
1253 FAIRWOOD CT El 01:12
® ❑ RELATED ❑Y ®N 10 17 2025 ❑AM ❑YES ®NO U1 -<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR 0 SLOW 15 '
❑ FT/MI NESW 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 0 PARKED 0 DRIVERLESS 0 RED 0 PEDAL 0 EWES p Nuv p!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEOAREA(S) Mao TOWED U1 Q
MCGURN. BRIAN.J. 0 5 /
yr 13-UNDER CARRIAGE 10l ! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 i� 6 �r COM VEH 0 ZgJ 1 n
~ MC EWEN IL 37101 0 1 0 FIRST CONTACT 5 7_: R-O =IIYes.SeeSidebar U1 0
Z 139320C IL 2026
TELEPHONE
IL D 0 1GBOGRFF8H1144501 EVEREST NATIONAL ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 TRUST LSR PETERSON C RM8CA00050-231 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 0
p DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NOV 0 NCv 0 Dv
yr
o _ 13-UNDERCARRIAGE 10,i Ic. 2 FIRE 0 El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 21 SPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 a ❑ El Y N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
POINT OF 8 I 4 U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 COM VEH ❑ ® W
FIRST CONTACT 11 Y �� -5 •If Yes.See Sidebar C
~ EL81408 IL 2026 RE 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5GRGN23UX3H133492 FARMERS GROUP ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
OLVERA. RUBIN 7571209890 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 10,17 /2025 01 12 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 28 99 + ! 0 PM• 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a MCGURN. BRIAN.J. 3-707 374001346 / ! PM
-, ARREST NAME ❑
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
25
t 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 374-Rizzu-o. Michael 501 360-Yucaitis 11 ,04,2025 01 30 ®pM Workers present? ®N U2 25
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
Not To Scale J BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ - } (example:shuttle or charter bus):or 0
-----A-. N
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 �
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 �
L L-__-a.-- 1253WWAIRW000xT Qua - t } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
' placarding(example:placards will be displayed on the vehicle). XI
1 -I
CARRIER NAME Z
i, i O
'I 1 - -- ADDRESS 0
(A
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Red
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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE