HomeMy WebLinkAbout2025-00071289 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1 li III 11 1111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00401 7259
u, 1 U2 3 4 1 U1 4 U2 U, 1 1_12 U199 U2 3 8 U199 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El 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 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED YR 2025I 2025-00071 Z89 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
190 WB EXPY Elgin 00:15
® ❑ RELATED ❑Y ®N 11 02 2025 ®AM ❑YES IX]NO U1 -<
g PRIVATE mo !day!yr ❑PM FLOW CONDITION ITl
FT/MI N E $ W N RAN DALL WB ENT RAMP COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) Nissen. Nathan. D. 0 mol / yr/1 9 8 8 Dodge Challenger 2021 �00-NONE t1_ 12 `_, DUE TOCRASH ® ❑
�.:!UNDER CARRIAGE 101 !. 2 FIRE 0NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 M
M 2 SY4 ❑Y ❑STM NECD UNK VEH. 9 ATCRASHD 9 99-U 15-UNKNOWN THER9 t6•TOP 3 `Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;il_6 I,.4 COM VEH 0 0 1 0
ELGIN N I L 60124 0 1 0 FIRST CONTACT 13 7 ; _5 *IIYes.See Sidebar U1
Z FM14561 IL 2026 REAR
TELEPHONE
IL D 0 2C3CDZKG7MH642074 Geico ❑Y ®N U2 M
S EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Elgin Fire 99 9 Same 6133027968 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
yr 12 _ C1
o 13-UNDER CARRIAGE 10.i t, FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction
value U1 3 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I,_
CIOMs gee SidebarH
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0
1 3 11 / F 2 5 0 1 0
I71
/ / #OCCS >
/ / UIZ D
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 1 2 11 ;02 /2025 00 15 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 ,,
v t 2 0 9 50 28 11,02 ,2025 00 19 ❑PM El Construction
>F
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ®AM ❑Maintenance U2
- Ela,
o ARREST NAME Nissen. Nathan. D. 11-601 1553-000237 11,02/2025 00 25 ❑PM SLMT
U 1 ❑ BI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM Utility
t 2 El ARREST NAME Nissen. Nathan. D. 11-503-A-1 1553-000236 1 1,02 ,2025 01 15 [M PM El Unknown work zone type U1 50
n 7 •
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ 1563-Rodriguez.Carlos 901 363-Vartanian 12 ,22,2025 09 00 ®❑PM Workers present? ®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 -<
c ` --I -' I. INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. _ I.
(example:shuttle or charter bus):or
0
1 r„, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
`✓ I. } } transporting employees in the course of their employment(example:employee
POT,p�,,,�� transporter-usually a van type vehicle or passenger car):or w
_..
4. Is used or designated to transport between 9 and 15 passengers,including (,)
C
i. ------;----; - } } } g po passen rs,includi the driver,
`,� for direct compensation(example:large van used for specific purpose):or O
L____a____. t _ _ l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m
I. placarding(example:placards will be displayed on the vehicle). ;p
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/.w I '- �, CARRIER NAME Z
�� I I ADDRESS D
I fs
I 0
I CITY/STATE/ZIP
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MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __. - 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? 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
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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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
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_TOWEDDUET DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE