HomeMy WebLinkAbout2025-00071464 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111111111111
IIIIII
II II II fl 11111
I)III )III II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X�01r294
u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U, 1 U2 1 4 2 U, 1 U2 1 *P 0 1 1 9
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 14
VEHICLE/PROPERTY ❑OVER 31,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00071464 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 mSHULER ST Elgin08:04
® ❑ RELATED ®Y 0 N 11 02 2025 ❑AM ❑YES El NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W S EDISON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 21 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Ulber. Kashten. K. 0 7 /
yr 13-UNDER CARRIAGE 1 lE
91 !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED ❑ 0 U2 0
m
M 5 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
El N ID UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r L S CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_i i COM VEH 0 0 1
c Z ELGIN IL 60123 B 1 0 FIRST CONTACT 3 7_•; __5 *II Yes.See Sidebar U1
0
REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
( NIA ❑Y ❑N U2 1"-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 52 1 Same NIA 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 0
m E{ DRIVER ❑ PARKED 0 ORIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0 NOV 0 DV CIRCLE NUMBER(S) U1
!2 O 0 6 Chrysler Pacifica 2012 00-NONE 1("j Q�,-_, DUE TO CRASH ❑ 2 x
.. Yr 13-UNDER CARRIAGE 10( ) FIRE 0 ® U2 C
il
M 3 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N El UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0
POINT OF 8 i1�i 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •If Yes.See Sidebar
ZC
St Charles IL 60175 0 1 FN57109 IL 2026 I 0
D
IL D 0 2C4RC1 CGOCR151301 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Sunderlage. Lisa.C. PAI L00012369 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)r{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 11 ,02 l2025 08 04 ®AM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n
T
43
2 ❑ 2 99 ) ! ❑PM ❑Construction X
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a ARREST NAME / / El PM '
02. N ® 13 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,_,Utility SLMT
t 2 ARREST NAME ❑AM
T PM 0 Unknown work zone type U1
El r DI
OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1515-BellEck.Stacy 601 , ! ❑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 -<
c ` -'- ' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
—Not TO smite.J } (example:shuttle or charter bus):or C)
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
v I')�I - } } } transportingemployees In the course of their employment
ployment(example:employee
i. l ♦� transporter-usually a van type vehicle or passenger car):or w
' • a . 4. Is used or designated to transport between 9 and 15 passengers,including cC/t
}--- ----; - •} } } g po passen rs,includi the driver,
IOW for direct compensation(example:large van used for specific purpose):or
L a--- I - t 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). ;p
—1
r 13°°IEI s . I . I
CARRIER NAME Z
ADDRESS 'n
V)
C)
CITY/STATEJZIP �
MOTOR CARR.ID 0 Interstate 0 Intrastate
l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. m
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
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE