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HomeMy WebLinkAbout2025-00069844 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 II II III II II II IIIII )III DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004006563 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 u1 1 U2 1 1 10 u, 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00069844 VENT ADDRESS NO. HIGHWAY or STREET NAMECITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I 0 0 RELATED ®Y ❑N 10 26 2025 ®AM ❑YES ®NO U1 -< DOUGLAS AVE Elgin00:19 g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl • 0 !MI N E S W Symphony COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 ,A ® Way Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 0 FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 1 1 FOR DAMAGEDAREA(S) FRONT TOWED U1 O / / Dodge Ram 1500(pickup) 2004 00-NONE ©, 12 , DUE TO CRASH 0 NAME(LAST,FIRST,M) Swanson- Maxwell.T. mo yr g 13-UNDER CARRIAGE 9) I! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O THERDISTRACTED 0 ]$I U2 4 <<Tl M 2 SYTM 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it S �i 4 COM VEH 0 j$J 1 0 ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_:, __5 *II Yes.See Sidebar U1 Z 2539571B IL 2025 REAR TELEPHONE IL D 0 1 D7H U 18D44S617728 American Alliance ❑Y Igl N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 EASTRIDGE, DAVID, E. ILT6116105 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER RESPONDER 2 eu 1 9 8 2 Ford Bronco 2025 00-NONE O Q�-O DUE TO CRASH ❑ 2XI 0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0 POINT OF 8 i1�i" 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 11 7 _,L_5 •If Yes.See Sidebar — Bourbonnais IL 60914 0 1 0 FM76663 IL 2025 I 0 C D IL D 0 1 FMEE4DP7SLB12913 Country Financial ❑Y 123 N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 SWASTEK, ERIK P010270722 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 3 08 / 2 3 0 1 0 m / / S#OCC D 71 / / U1 1 D / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z N 1 ® 11 1 10,26 r2025 00 19 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) o" 2 ❑ 06 99 , , 0 PM ❑Construction * Z 3 ❑ lyg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Swanson, Maxwell.T. 11-902 S1544000231 / / El PM SLMT o N ElCITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 25 t 2 ARREST NAME AM 7 1 1 ❑❑PM ❑Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1544-Solis,Yulissa 202 391-Jacobucci 11 , 17,2025 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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is . L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , 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 0 L L___-a____.: L L L ...._-..:_____� t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m 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? ❑ Yes II No ElUnknown 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 TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue Gray 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: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE