HomeMy WebLinkAbout2025-00071515 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00401727S
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00071515 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED ®Y 0 N 11 03 2025 ®AM ❑YES ®NO U1 -<
E HIGHLAND AVE Elgin 08:06
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT l MI N E S W DOUGLAS AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 5 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGEDAREA(S) FRO T TOWED U1 O
Dou las.Thomas.A. 0 1 /
yr 13-UNDER CARRIAGE EN
O i FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 ]$I U2 0 rr1
M 2 SYTM 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER 0916-TOP3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D;i�S �'.4 COM VEH ❑ Ea1 O
= ELGIN I L 601 20 0 1 0 FIRST CONTACT 9 7 •' __5 •IIYes.See Sidebar Ut
Z BY73381 IL 2026 E
TELEPHONE
IL D 1 FMCUOGX8DUB52137 Direct Auto ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
Douglas. Damien PAI L001242402 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 eu
�{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
/1 9 9 2 Yr El Dorado MfgElfltadado Axess 2022 00-NONE O Qi-O DUE TO CRASH ❑ ® 33
0 13-UNDER CARRIAGE 10( l 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ® ❑ U1 CO
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
~ 60110 0 1 0 M234388 IL IC
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M
IL B 7 1 N9ALALM7NC084162 Self Insured ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
PACE BUS N/A BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
u1 =
(UNIT) (SEAT) IDOBi (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)({ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 6 08 /
:A
/ / UI 1 D
/ / 2 O
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 11 ,03 /2025 08 06 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 06 99 , / ❑PM ❑Construction *
Z3 0 I!!I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
o1 ® 11 1 ARREST NAME Douglas.Thomas.A. 11-801 1547000159 / / ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
t 2 0 ARREST NAME AM
7 , / pM El Unknown work zone type 25
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1547-Steele.Justin 101 12 ,02,2025 09 00 ❑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 truckrtrailer -<
c ` '' -' r INDICATE NORTH combination):or —I
A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N I ...)1410070.41 } (example:shuttle or charter bus):or 0
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
` -A- - ; Not To Scale `
es pa g pe
I } } } transporting employees in the course of their employment(example:employee � �
�/ transporter-usually a van type vehicle or passenger car):or CO
1 l
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g po passen rs,includi the driver,
,�a for direct compensation(example:large van used for specific purpose):or O
L L____a____.I — — — Ii — — — _ t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). XI
D
um� - CARR NAME PACE 1
r r T 1 r ADDRESS 550 ALGONQUIN RD
CITY�STATIERFJZII> 1 1601BUS10 n
cn
MOTOR CARR.ID 0 Interstate El 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
. 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 ®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 Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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