HomeMy WebLinkAbout2025-00072891 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 1111101100111 fll I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004028891*
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00072891 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m1050 BLUFF CITY BLVD Elgin05:00
® ❑ RELATED ❑Y ®N 10 05 2025 ❑AM ❑YES ®NO U1 —<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ FT/MI NESW Cook HIT ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 8 !
yr 11-_ 12 -
13-UNDER CARRIAGE 10l 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 9 ALGN =
❑ El N ID VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i� B i.r.4 COM VEH ® 0 1 0I— FIRST CONTACT 5 7 _- -1 •II Yes.See Sidebar U1 0
Z 60110 0 1 4031257B IL 2026 REAR
TELEPHONE
IL D 1GCPSBEK4S1140208 ACE AMERICAN INSURANCE CO ❑Y ign4 U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ISA H0889302 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 21 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NOV 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr 13-UNDER CARRIAGE ta,i 2 FIRE 0 (21 U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 0 ® SPDR n
❑Y ❑N D UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value U1 0 -
POINT OF 8 )
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR}._ COM VEH r ❑ CO
F„ FIRST CONTACT 11 7 , _5 C.
If Yes,See Sidebar
122714TW IL 2025 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1FDXX47F12EC26982 PEKIN INSURANCE COMPANY ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 99 =
Maringas Towing Inc 006481235 BAC
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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)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 CD 18 1 11 ,11 /2025 09 30 ®❑AM in a Work Zone? ®N DIRP co
1 Nt PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 30 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
—a, ARREST NAME / / ❑PM '
o N El 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
35
t 2ARRESTNAMEAM
7 ❑PM 0 Unknown work zone type U1
El 1 / ❑
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
441-Alva. Edwin 401 275-Engelke , ! ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; ; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP I n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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
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
Gray White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE