HomeMy WebLinkAbout2025-00069783 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets Mill I0110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO040Q13187
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and!or Tow Due To Crash
0 AMENDED YR 2O25I 2025-00069783 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 m
® ❑ RELATED PRIVATE ❑Y ®N 10 25 2025DAM ❑YES ®NO U1 -<
S LIBERTY ST Elgin mo /day/yr 07:15 ®PM FLOW CONDITION m
_
75 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 15 cn
® ®!MI N E p W Villa St WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 FRCrar TOWED U1 0
NAME(LAST,FIRST,M) p mo yr
Cam bell.Clarence. E. Yamaha YZF-R3 2004 00-NONE „ 12 i DUE TO CRASH ® ❑
13-UNDER CARRIAGE 101 ! 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 17 4 ❑Y ®SNE❑ n 15-OTHER
UNK VEH. ATCRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iL a 4 COM VEH 0 Ea 1 0
ELGIN I L 60120 0 1 0 FIRST CONTACT 14 7_; _5 *II Yes.See Sidebar U1
Z MCYEB104 IL 2025 REAR
TELEPHONE
IL D 0 JYARN13E14A004706 None ❑Y ®N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Rodriguez.Jared.V. None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
m N DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 MAV 0 NCv 0 DV
!1 9 9 6 Ford Escape 2021 00-NONE O, t2..-_, DUE TO CRASH 0 [gI 2 x
0 Yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5
If Yes.See Sidebar
FIRST CONTACT 11i1 Ii 4 COM VEH 0 ® U1 to8 7 _5 •
H Hampshire I L 60140 0 1 0 CX49719 I L 2026 REAR0 N
IL D 0 1FMCU9G68MUA29949 Allstate ❑Y ®N RDEF X1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Broadnox.Shannon 811092666 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 10,25 ,2025 07 15 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 2 99 10,25 ,2025 07 15 ®PM 0 Construction
*
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Campbell.Clarence. E. 3-707 1512603 10,25,2025 07 21 ®pM• • ❑Utility SLMT
MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 El ARREST NAME Campbell.Clarence. E. 11-902 1512602 10,25 ,2025 07 40 0 PM El Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
1512-Juarez-Huichapan.Juan 400 12 ,02,2025 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.
r ----r••--, , ` Not To Scale I A CMV is defined as any motor vehicle used to transport passengers or property and: z
r IL An
l combination): r more than pound (example:truck or truck/trailer 1. Has a weight rating10 000 5 i -<
--J
INDICATE NORTH Ilon)o p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
i I N _ (example:shuttle or charter bus):or 0
L A — I I� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
- } } } 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 the driver. C
j Villa/St for direct compensation(example:large van used fors cific purose):or to
__ It i. < 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). m
Point?of?corftact D
CARRIER NAME —I
/ VQ�cr}VIII� - L. __ ADDRESS 'O
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e I•_i CITY/STATE/ZIP g
I l . . . . .. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. Not in Comm./Other
0
• USDOT NO. ILCC NO. C
Xi
Source of above 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE