HomeMy WebLinkAbout2025-00070615 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110 1111
IIIII III II)III IIIIII
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X0D401 1266
u, 1 U21 1 4 1 U1 7 U2 1 U, 1 1_12 1 U1 1 U2 1 5 11 u, 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00070615 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 10 29 2025 ❑AM ❑YES ®NO U1 -<
S RANDALL RD Elgin mo /day/yr 06:25 ®PM FLOW CONDITION M
gi0g&MI N EON Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ElSLOW 15 u)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
(g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑/Cv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 0NAME(LAST,FIRST,M) Patterson. David.W. 1m o /1 9 6 8 Honda Accord 2016 00-NONE „ Oi_, DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 , 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 3 <<T1
M 2 5 SYTM❑Y ®S NE❑UNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 76•TOP 3 `Distraction Value ALGN X.
r COM VEH 0 Ea 1 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1a 4 0
F. FIRST CONTACT 12 7 _5 *If Yes.See Sidebar U1
Z Crystal Lake IL 600012 0 1 0 S819577 IL 2025 ,
TELEPHONE
IL D 0 1 HGCR2F5XGA095660 State Farm ❑Y I l N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 1954571 SFP 13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 i v 0 Dv
/1 9 8 4 Honda Pilot 2021 00-NONE 11 12'-_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI S I',_4 COM VEH ❑ ® in CO
FIRST CONTACT 6 Y__{_Os•_5 •If Yes.See Sidebar
= ELGIN IL 60124 0 1 0 EF64399 IL 2026 aR
IL D 0 5FNYF8H25MB038224 Allstate ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 922938980 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOBI (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 09 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 10,29 /2025 06 25 ®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• ❑Construction >E
N 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Patterson. David.W. 11-601-Ax S1529-000534 / / 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
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1529-Audi red.Jonathan 702 391-Jacobucci 12 ,02/2025 09 00 D PM Workers present? ®N U2 45
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.
I
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: D
zi
-<
r alr:la .>Il
ult
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
combination):or
r }-- -r- --, I I I I = - r INDICATE NORTH p1
I I ' r _ N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I _ - } (example:shuttle or charter bus):or
Cc 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
.ii } } } transporting employees in the course of their employment(example:employee X
la ———— e transporter-usually a van type vehicle or passenger car):or CO
L 4. Is used or desi nated to trans rt between 9 and 15 ge ng C
----------; A I _ r } } } g Po passen rs,indudi [he driver,
I• for direct compensation(example:large van used for specific purpose):or
w
O
' a ., t i ,_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m I- I------`-----I r
placarding(example:placards will be displayed on the vehicle). XI
M
—1
CARRIER NAME Z
ADDRESS 0
Not To Seale] CITY/STATE/ZIP 0
_ i. i. i. MOTOR CARR.ID 0 Interstate El Intrastate 0
I I . I • ❑ Not in Comm./Govt. 0 Not in Comm./Other
I ‘I.
- 'r----Y----, USDOT NO. ILCC NO. m
unit 1 , , ' , 71
Source of above z
0 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
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
Silver Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE