HomeMy WebLinkAbout2025-00078544 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II IIIIII U I� II lUll UI 11011
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00078544 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 8 �I
W CHICAGO ST El08:24
® ❑ RELATED ❑Y ®N 12 10 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W N CRYSTAL AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW Cl)
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
CO AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 8 !
yr Other Other 2019 00-NONE „ Q _, DUE TO CRASH ❑ VIE
13-UNDER CARRIAGE
0} :al FIRE ❑ NIC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ]$I U2 m
M 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 t6•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_ 6:i1 4_5 *IIYes.See Sidebar U1 0
F. FIRST CONTACT 12 7 , COM VEH Il ❑ 1
Z Oak Grove KY 42262 0 1 0 P1025354 IL 2025 is
TELEPHONE
KY Other 7 4V4NC9EH3KN211199 Transverse Insurance ❑Y ®N U2 93 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
TH K Trucking Inc TNCA0022997-25 3 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 (,0j
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ 71
.0 13-UNDER CARRIAGE 10.i t, FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 1,_5 CIO es See SidebarEH
❑ C
CO
F` REAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 28 1 Union Pacific Union Pacific Bridge 12,10 /2025 08 24 ®❑pM AM 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
v t 2 0 327 SPENCER ST West ChiNago 60185 14 15 ! , ❑PM El Construction *
Z3 0 Ei CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME Sanders.John. R. 11-601 1556000121 , ! 0 PM
o U 1 0 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o N El
AM 15
t 2 ElARREST NAME 12/10 12025 09 30 [M PM ElUnknown work zone type u,
n 2 3 0
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1556-Sanchez.Jimena 601 397-Jones 11 , 12 ,26 09 00 ❑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- ' r INDICATE NORTH combination):or -I
Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- I _ (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} A i
. r r Jr
CO } } } transporting employee In the course�of their empbyment(example:employee 7
11 transporter-usually a van Type vehicle or passenger car):or C
L i.-------- t 4. Is used or designated to transport between 9 and 15passengers,includingy} } . for direct compensation(example:large van used for cific purpose): the driver,
vna,�oter Pe ( P 9 Pe P pose):or O
L L____a..... __. L l. l 1 t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
A
i I* t t I------1-
, . _ CARRIER NAME THK Trucking Inc Z
ADDRESS 562 W LORRAINE AVE t7
T.
, 0
CITY/STATE/ZIP Elmhurst 1 I L 160126 n
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm/Gout. ❑ Not in Comm./Other
�" --- --1 - USDOT NO. 1526463 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 M
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash? A
❑ Yes I 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 VIM 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE TO VEHICLE CONFIG. 4 CARGO BODY TYPE 2 LOAD TYPE 9