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HomeMy WebLinkAbout2025-00071840 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 12 Sheets 01111101111 0110 1111 fl 10011001111I100 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004018184 u, 1 U2 1 1 1 U116 u2 u, 1 U2 U, 1 U2 1 6 u, 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ID OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00071840 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 5 �l ® ❑ RELATED ❑Y ®N 11 05 2025 ®AM ❑YES ®NO U1 -< W CHICAGO ST Elgin 07:28 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITI FT!MI N E S W N CRYSTAL AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 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 Qg3 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 3 / yr 13-UNDER CARRIAGE NI 101 ! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 M F 2 SYTM IN ENGAGEis-OTHER 4 ❑Y ®S NE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9©TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF il_6 I,.4 COM VEH I1 El 0 f. FIRST CONTACT 16 7_;—,__5 * (Yes.See Sidebar U1 Z Cicero IL 60804 0 1 0 P1216171 IL 2025 REAR TELEPHONE IL B 7 3ALACYFE9RDVB5919 Trisura Insurance Co ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 1 99 9 American One Limo IN KAA013392502 1 rn o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 30 X ❑ DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 row yr 12 - C o 13-UNDER CARRIAGE 10 I c. 2 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 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 1._ CIOMs gee SidebarH ❑ C CO F` REAR` co 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 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 1 8 08 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y N 1 ® 28 1 Union Pacific Union Pacific Bridge 11 ,05 /2025 07 40 ®❑pM in a Work Zone? Igi N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v 1 2 0 200 N 6TH ST Dekalb IL 60115 15 18 / / 0 AM ❑Construction * Z3 0 El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME Miller. Lou Ann 11-305-A 435000724 / / ❑PM SLMT o U 1 0 0 CITATIONS ISSUED PENDING Utility SECTION CITATION NO. ROAD CLEARANCE TIME o N 0• AM 25 t 2 ElARREST NAME 11/05 /2025 08 00 M PM ElUnknown work zone type U, n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ❑ ❑qM Workers present? ❑Y 435-Mahan. David 601 407-Sproles 12 /01 ,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 -< ` ` --I -' I. INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r ,. (example:shuttle or charter bus):or 0 t 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O - ------I-----I I I - }} } transporting employees in the course of their employment(example:employee X .; le transporter-usually a van type vehicle or passenger car):or w C '"" I. 4. Is used or designated to transport between 9 and 15 passengers,including N� }-----;----; - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O I. 11. . . . 411 .L i. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D "- placarding(example:placards will be displayed on the vehicle). XI -I • Not To Scale CARRIER NAME Infinity Transportation Management z ADDRESS 2400 E DEVON ST 268 D _. GI i CITY/STATE/ZIP Des Plaines 1 IL 160018 g MOTOR CARR.ID 0 Interstate El Intrastate I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other '` -- -- I. % % USDOT NO. 2554364 ILCC NO. m XI Source of above z . own tank)? 0 Yes ® No 0 UnknownT. 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 ®No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White 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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE