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HomeMy WebLinkAbout2025-00074734 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M 11111111 II 111111H 11I11 OO UU DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004040685 u, 1 U21 3 4 4 u,16 U2 1 U, 1 u2 1 U1 1 U2 1 4 11 u1 1 u2 1--1 *P 0119* 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 ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ❑AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025512025-00074734 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 11 S MCLEAN BLVD El In ® ❑ RELATED ❑Y ®N 11 20 2025 ❑AM ❑YES ®NO U1 -< 03:55 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT/MI NESW 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 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n Nr FOR DAMAGEDAREA(S) 1630 _O TOWED U1 I� NAME(LAST,FIRST,M) mo /2 0 0 2 Chevrolet Malibu 2012 00-NONEVI 13-UNDER CARRIAGE © NI ,, 2 OUE TO CRASH El 0,,: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ® 0 U2 4 rn M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN 916•TDP3 `Distraction Value 5 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4 COM VEH 0 Ea 1 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_:, __5 *II Yes.See Sidebar Ut ZDZ74717 IL 2026 REAR TELEPHONE IL D 0 1 G 1 ZC5E04CF397520 Statefarm ❑Y ®N U2 1- in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 1414156-SFP-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 I v ❑DV /1 9 9 0 Chevrolet Malibu 2017 00-NONE 'o,1 t2 c,�2 FIRE DUE OCRASH D ® U2 2 C o — 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,�=Q)OS •If Yes.See Sidebar C ELGIN IL 60123 0 1 0 FN48121 IL 2026 IAR Si)0 IL D 0 1 G 1 ZESSTOH F155145 Kemper ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 12RA000066887 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPOND❑N u1 = (UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) OHM 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL) 2 6 01 / :A / / UI 1 D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 11 /20 /2025 04 12 ®AM in a Work Zone? ®N DIRP co 1 1 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 28 03 11/20 /2025 04 03 ®pM El Construction R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 3 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Boley.Trace. M. 11-601 W1543000284 11/20/2025 04 06 Igi pM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility T 2 El ARREST NAME 1 1/20 /2025 04 46 ®PM El Unknown work zone type U1 0 AM 3O 2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35 1543-Sturgeon. Kyle 600 391-Jacobucci 12 /23/2025 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 NAL UNITS FORMS. Y.---, I I I L A CMV is defined as any motorDvehicIIe J Ie used to transport Z port passengers or property and: lefkin7AYe 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` --I -' r INDICATE NORTH combination):or —I — — — — BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or _ X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X — — — — transporter-usually a van type vehicle or passenger car):or w i. i. __}----; - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C c for direct compensation(example:large van used for specific purpose):or O < i.____a____; I Iti I I _ t i i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •u placarding(example:placards will be displayed on the vehicle). XI m Ito I tg 2:. CARRIER NAME Z II I I _ ADDRESS D CLaz �P.O I —�—T K 117S?Mclean7Blvdi. 0 _ 4. CITY/STATE/ZIP g I I k✓ i. .� MOTOR CARR.ID 0 Interstate 0 Intrastate I I I ❑ Not in Comm./Govt. ❑ Not in Co mm./Other 0A C Not To Scale N f f f f USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard O 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 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 Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE