HomeMy WebLinkAbout2025-00068841 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 111110 fl fl VOlVO
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0040OO815
u, 1 U21 1 1 1 U1 2 U2 1 u, 1 1_12 1 U, 1 U2 1 1 15 u, 1 u2 1 *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 El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00068841 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
195 NESLER RD Elgin® ❑ RELATED ❑Y ®N 10 21 2025 03:10 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 u)
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 O
NAME(LAST,FIRST,M) Johnson. David.A. m0 0 / /1 9 5 3 Mercedes-Ben2500 2018 00-NONE 1.,.. Q T i 0 DUE TO CRASH ❑ VI
13-UNDER CARRIAGE 10 i : 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 M
M I 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_1a �i 4 COM VEH 0 0 1 0
F. FIRST CONTACT 1 7_ ;__5 *II Yes.See Sidebar Ut
Z Glen Ellyn IL 60137 0 1 0 AT40976 IL 2026 REAR
TELEPHONE
IL D 0 WDDUG8GB4JA409199 Progressive ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 949886632 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER X*
Refused 0 Y ® N 2 XI
x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑iiuv 0 iv ❑DV
/1 9 8 2 Volkswagen Atlas 2018 00-NONE OI t2 ! 2 FIRED CRASH ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
POINT OF 8 i1�I 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5
FIRST CONTACT 11 7- -5 •If Yes.See Sidebar
H HOFFMAN ESTATES IL 60192 0 1 0 NXF1951 TX 2026 I 0
IL D 0 1V2TR2CA8MC524549 Allstate ❑Y 123 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same 974517162 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N ui =
(UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS) TELEPHONE) (EMS) (HOSPITAL)
2 3 11 /
. D
/ / 4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,21 /2025 03 10 0 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
o"
2 0 28 99 , / ❑PM• ❑Construction
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Johnson. David.A. 11-601-Ax S1529-000527 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
t 2 ❑ ARREST NAME AM
7 , / pM El Unknown work zone type 45
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1529-Audi red.Jonathan 801 12 , 2/ ,025 09 00 ❑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
Ct17)
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
-<
i- }____r____1 - } INDICATE NORTH combination):or -I
0 p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
i_ - } (example:shuttle or charter bus):or 0
Nesler?Rd
L A ; 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } } transporting employees in the course of their employment(example:employee
�__ I transporter-usually a van type vehicle or passenger car):or w
L L.___a__ r - 4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
3;. . t } } for direct compensation(example:large van used for specific purpose):or O
L ..i.. - Ili• - - - - - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
-I
CARRIER NAME Z
ADDRESS 0
C)
CITY/STATE/ZIP g
- MOTOR CARR.ID ❑ Interstate ❑ Intrastate 5
Not To Scale 0
r ; 0 Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. ❑ Yes II 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
11
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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