HomeMy WebLinkAbout2025-00078139 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets IIIIII 11 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004066550
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INVESTIGATING AGENCY DAMAGE TO ANY El$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 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00078139 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y 0 N 12 08 2025 ®AM ❑YES ®NO U1 -<
UMBDENSTOCK RD Elgin10:52
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT l MI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑V #OF MOTOR ❑SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
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lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0
0 9 !
yr . Q
13-UNDER CARRIAGE 16 i : 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 00 r<r1
M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�6 �i COM VEH 0 ZgJ 1 0
~ Bensenville IL 60106 0 1 0 FIRST CONTACT 1 7 ; __5 *Ifves.SeeSidebar U1
Z JAY57-WS I L 2026 REAR
TELEPHONE
IL D 0 5FPYK3F84NB027939 Auto-Owners Ins Co ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 82-708-759-09 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
m �{ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEON. 0 EWES 0 row 0 NCv 0 DV CIRCLE NUMBER(S) U1
/1 9 6 8 Ford Transit Connect 2023 00-NONE 11_. 12 "_, DUE TO CRASH ❑ C 2
o 13-UNDER CARRIAGE o 1 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i l!.4 COM VEH ❑ ® U1 W
FIRST CONTACT 9 7 , _5 •If Yes,See Sidebar C
BARTLETT IL 60103 0 1 0 190330C IL 2026 I 0Si)
IL D 0 1 FTBR2C88PKB32658 Old Republic Ins Co ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Wheels LT LSR Gordon MWTB 314880-25 BAC
$
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)
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 4 12,08 /2025 10 53 ®❑pM in a Work Zone? NJ DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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2 ❑ 2 99 + ! ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Snyder.Jay. D. 11-901-A 495000467 / / El Pm SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
t 2 ❑ AM
ARREST NAME 1 / ❑❑PM ❑Unknown work zone type U1 3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45
495-Sjodir.Jacob 702 01 1 20,2026 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
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- }-- -'-----' - I CATE NOR combination):or
IV NDI TH C
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
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umm 3. Is tl geed t carry 5 fewer passen ers and o rated a contract carrier O-_ I eS o 1 or
"I I. } } transporting employees in the course of their employment(example:employee I w
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transporter-usually a van type vehicle or passenger car):or �
"°P°�"°°d } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
ill for direct compensation(example:large van used for specific purpose):or O
L L____a____. _ _ _ linii _ _ _ 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). XI
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CARRIER NAME
ADDRESS Z
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I _ CITY/STATE/ZIPn
Not To Scale I i. i. MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ 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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BYlT6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE