HomeMy WebLinkAbout2025-00070520 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 11111111 IIIIII II 1111 flI 101100100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ® B Injury and/or Tow Due To Crash YR 202512025-00070520 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
1025 N MCLEAN BLVD EIIn11:22
® ❑ RELATED ❑Y ®N 10 29 2025 ®AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NOV ❑NV., ❑EN DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 5 /
yr
Grayer.Ton T. Hyundai Tucson 2022 00-NONE ,, 12 , OUE TO CRASH ® 0
E
13-UNDER CARRIAGE FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0U2 0 m
M 2 SY 15-OTHER
4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH 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 $_iL a i COM VEH ❑ Ea 1 0
~ BELLWOOD IL 60104 0 1 0 FIRST CONTACT 1 7_; __5 *lIVes.SeeSidebar Ut
Z FG25616 IL 2025 REAR
TELEPHONE
IL D 0 5N MJ B3AE6N H002594 NIA ®Y ❑N U2 13 . Rr'I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1
Pruitt. Dedriana. D. NIA 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NAV 0 Ncv ❑Dv
yr 12
o 13-UNDERCARRIAGE 10;i 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 916-TOPO3 * X
❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN 0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i B 1Y 4 COM VEH D ® U1 CO
FIRST CONTACT 1 7 _, _5 •IfYes.See Sidebar C
E LG I N I L 60120 C 1 0 M P22754 I L 2023 REAR 0 N
M
IL D 0 1 FM5K8AC9PGB13403 Charter Oak Fire Insuranc ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
City of Elgin.City of El 8109160P901 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 5 10,29 r2025 11 22 ®AM❑PM in a Work Zone? ®N DIRP D
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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
0 2 ❑ 28 15 ) ) ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
- U2
a, ARREST NAME Grayer.Tony.T. 3-707 748251 / r ❑❑PM ❑Maintenance SL
o N ER 1 5 •
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility MT
15
t 2 ARREST NAME AM
7 r r ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 10
1556-Sanchez.Jimena 502 397-Jones r r ❑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
___ ____; r Not To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c '' - INDICATE NORTH combination)or .Z—I1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} L - (example:shuttle or charter bus):or A. X
; ; I _un;r, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
r,J ® } } } transporting employees In the course of their employment(example:employee
El _ transporter-usually a van type vehicle or passenger car):or CO
' . 4. Is used or designated to transport between 9 and 15 passengers,including W
--- ----; !' 1omawau,r,,.asa } } } g po passen rs,indudi the driver,
1 for direct compensation(example:large van used for specific purpose):or O
L L____a..... 3 our t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
5 i i placarding(example:placards will be displayed on the vehicle). ;p
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�;;:-.,1 CARRIER NAME Z
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ADDRESS
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __.; - USDOT NO. ILCC NO. m
XI
Source of above z
• m
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 ❑ 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
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_Mies . 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