HomeMy WebLinkAbout2025-00072062 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III 11 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004024-481
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00072062 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 21
® ❑ RELATED 0 Y ®N 11 06 2025 ®AM
225 WILLARD AVE Elgin 09:57 ❑YES ®NO U1
_ PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 99 to
❑ FT/MI N E S W Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ 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 NIAV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
NAME(LAST,FIRST,M) Manning.Taylor. R. 0 4 /
yr 13-UNDERCARRIAGE 101 �. 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 M
M 2 4 SYSTM❑Y El NE UNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER ()TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ij 4 COM VEH ® 0 1 0
F. Metairie LA 70001 0 1 0 FIRST CONTACT 16 7_;1 __5 *II Yes.See Sidebar U1
Z 78KT2E MO 2025 MAR
TELEPHONE
LA A 7 3AKJHHDR8RSUR7683 Great West Casualty Compa ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Wilson Logistics MCP49994G 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 (,0j
§, ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES pa wV 0 KCV ❑Dv
yr , 12 _ xi
C
Ti 13-UNDER CARRIAGE 10 i z FIRE 0 ® U2 C
1 3 Y SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑ NJ ND UNK VEH. AT CRASH 99-UNKNOWN *OistractonValue 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI�1:- 4 COM VEH 0 ® U1 W
FIRST CONTACT 15 YA-1 .5 •IfYes.See Sidebar C
Z ELGIN IL 60120 0 1 0
0 Si)
NIA ❑V 0 N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Wilson Logistics NIA SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 09 / M 2 4 0 1 0
m
/ / #OCCS D
71
/ / UI 2 D
/ / 0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 20 5 Willard Services LLC Power Lines 11 ,61 /025 09 57 ®❑pM AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 225 WILLARD AVE ELGIN IL 60120 15 99 , / ❑AM El Construction *
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 99
❑AM 0 Maintenance U2
—a, ARREST NAME / / El PM '
o Nu 1 ® 20 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
15
r 2 ARREST NAME AM
T 1 / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 15
1547-Steele.Justin 302 , / ❑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
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
ssantuairxe - } (example:shuttle or charter bus):or
Not To Scale l 3. Is designed to carry15 or fewer
L L A g passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
<-1 transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including cC/t
i_ }-----;----; VI - } } } g po passen rs,includi the driver,
• cuer for direct compensation(example:large van used for specific purpose):or
L____a____. f _ _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
u
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Wilson Logistics Inc Z
ADDRESS 545 E EVERGREEN ST O
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tmI rn
CITY/STATE/ZIP Strafford I MO 165757 n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Gout. ❑ Not in Comm./Other
;____Y____1 - USDOT NO. 1009435 ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® 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 I 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'7 0 Yes ®No 2
TRAILER VIN 1 1 JJV532BXM L272476 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 ® 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH 75 F ft. NO.OF AXLES 2
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE 9 LOAD TYPE 5