HomeMy WebLinkAbout2025-00071283 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll 1111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00402509/
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00071283 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 71
VILLA ST Elgin® ❑ RELATED t3I Y 0 N 11 01 2025 11:36 ❑AM ❑YES 0 NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W S G I FFORD ST COUNTY PROPERTY :IY ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
! , FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown.0. Dodge Ram 1500(pickup) 00-NONE „ i DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,)[B !i,_ 1 0
~ 0 9 0 FIRST CONTACT 99 7_; _5 *IIYes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Same Unknown 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 99
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 NCv 0 DV CIRCLE NUMBER(S) U1
!1 9 8 8 Chevrolet Equinox 2013 00-NONE i1_"j t2'-_, DUE TO CRASH ❑ 2 x
0ay Yr 13-UNDER CARRIAGE ') 2 FIRE 0 ® U2 C
c II
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 6 .I. 4 COM VEH ❑ ® Ut to
FIRST CONTACT 6 �,�=Q)OS •)ryes.See Sidebar C
ELGIN IL 60123 0 1 0 FT65868 IL 2026 i 0 Si)
Z
IL D 2G N FLG EK8D6259036 Liberty Mutual ❑Y ®N RDEF X1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same aov2431908668056 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 4 06 /
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CO 11 9 11 /01 /2025 11 36 ®PM in a Work Zone? ®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
2 0 28 18 11l01 /2025 11 41 pM
® • ❑Construction
Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
ARREST NAME 11/01 /2025 11 44 ®pM
o N 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
30
r 2 ARREST NAME AM
7 / / O PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID1545-VanEycke. Brier tot 363-Vartanian / / ❑❑PM Workers present? ®N U2 30
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 0 r INDICATE NORTH comb natlon)or
Not To Scale I i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
L A }1 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
LI
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
L i — l. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
411520 placarding(example:placards will be displayed on the vehicle). XI
°nit t—tint 2.... —D7
�6.:J:J-� CARRIER NAME Z
I ,
ADDRESS
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CITY/STATE/ZIP n
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE