HomeMy WebLinkAbout2025-00071375 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110
II II fl III III Hil 00 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004016040`
u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119*
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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00071375 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :Ft
® ❑ RELATED ®Y 0 N 11 02 2025 ®AM El YES ®NO U1 -<
HOPPS RD Elgin 11:49
g PRIVATE mo /day/yr ❑PM FLOW CONDITION M
FT N E S W UMBDENSTOCK RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cn
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 C)
07 /1 9 9 0 r tf yr Mazda 6 2017 00-NONE 13-UNDER CARRIAGE 11, 12 7�1 DUE TOCRASH ® ❑ E
! �/ FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U al
O DISTRACTED 0 ga U2 99 I'T1
M 2 THER
6 ❑Y ®SYSNEM IN DUNK VEH. 0 AT CRASH ENGAGED 0 99-UNKNOWN 9 76-TOP(3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 it COM VEH 0 Ea 1 n
I� FIRST CONTACT 2 7 _1L-t-OS •IIYes.See Sidebar U1 0
Z ELGIN IL 60124 0 1 0 MADST-BH IL 2026 REAR
TELEPHONE
IL D 0 J M 1 G L1 X50 H 1110176 State Farm ❑v ®N U2 M
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1942755SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
rg-
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑m,ly 0 i v ❑Dv
� /1 9 yf 7 Mercedes-Ber1LC 300 2019 00-NONE 0. QI'-O, DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7 _, .5 •If Yes.See Sidebar
Z SOUTH ELGIN IL 60177 B 1 0 DE92128 IL 2025 I 0 N
M
IL D 0 WDCOG4KBXKV137075 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3549064SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co
DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 11 ,2/ /025 11 50 ®❑PM AM in a Work Zone? ®N DIRP D
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 2 23 11/2/ /025 12 00 ®PM ❑Construction *
R 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a1 ® 11 4 ARREST NAME Currie.John. M. 11-901-A 495000458 11/2/ /025 12 05 ®pM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
0 AM
t 2 ElARREST NAME 1 1/2/ /025 12 24 ®PM 0 Unknown work zone type U1 25
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑y 45
495-Sjodir.Jacob 702 11 / 18,2025 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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` '' -' r INDICATE NORTH combination):or —I
i 1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1
- (example:shuttle or charter bus):or n
r r r
Li
3. Is desgned to car 15 or fewer passengers and operated a contract carrier O
I. } } transporting employees In the course�of their employment(example:employee X
1 1 1 1 transporter-usually a van type vehicle or passenger car):or w
L L.___a____� '� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } 1. •
for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L i i t _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
— 44- — — — placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
_ __ ADDRESS 'O
T.
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
Not To Scale0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown 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 ❑ 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 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE