HomeMy WebLinkAbout2025-00073537 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00073537 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ❑Y ®N 11 14 2025 DAM ❑YES ®NO U1
N STATE ST Elgin03:37
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
5 !MI N E S W Tollgate Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 2 fA
g Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18: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 n
! ! FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 161 !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 4 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
$99 4 COM VEH 0 Ea
'a- CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I�6 li,_ 1
0 9 0 FIRST CONTACT 7 ;mai -5 *IIYes.See Sidebar U1 0
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
Unknown ❑Y ❑N U2 I—
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
> RESPONDER
y°®N X
m
N DRIVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV CIRCLE NUMBER(S) U1
!1 9 8 2 General MotorSiQoq 2022 00-NONE .1.,-1 12..-_, DUE TO CRASH ❑ 2 x
o Yr 13-UNDER CARRIAGE 10'I 2 FIRE ❑ ® U2 C
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .ilI 6 i.�., COM VEH ❑ ® u1 CO
FIRST CONTACT 7 O7 _i _5 •If Yes.See Sidebar C
Z Cary IL 60013 0 1 0 2528761 B IL 2026 rAR 0 Si)
D
IL D 0 3GTUUGED9NG690246 Farmers Insurance ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same 607071471 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 r 14 l2025 03 37 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
di, 2 0 28 18
N 3 0 0 CITATIONS ISSUED 0 PENDING ! 1 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / 0 PM '
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y
t 2 El ARREST NAME 11 r 14 /2025 03 37 ®PM 0 Unknown work zone type U1 30 0 AM
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1542-Chase. Ethan 501 - ! r ❑❑AM 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 truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
I I W Not To Scale 1 - (example:shuttle or charter bus):or
3. Is< <---- -•-•; I \ I
transporting employeened to s 5 or fewer inthe course passengers thir emand ployment operated
xample:employee
transporter
I.
}
transporter-usually a van type vehicle or passenger car):or
co
L I 4. Is used or desi nated to trans rt between 9 and 15 ge ng y
}-----;----; r� - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
, wr m
_ L t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
, m
.� placarding(example:placards will be displayed on the vehicle).
_D7
CARRIER NAME Z
_ __ ADDRESS 'O
D
/1.E '
�► I 0
I CITY/STATE IZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. own tank)? 0 Yes 0 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
71
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 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 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE