HomeMy WebLinkAbout2025-00078675 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 IIIIII UHI U
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED yR 202512025-00078675 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 12 10 2025 ❑AM ❑YES IX]NO U1 -<
LONGCOMMON PKWY Elgin mo /day/yr 09:30 ®PM FLOW CONDITION m
01 O�/MI N E O W Waterford Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 3 /
yr 2013 00-NONE
® 12 _1 DUE TO CRASH ® ❑ E
13-UNDER CARRIAGE 10 1 2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASIN H O 99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR0
F. POINT OF s �--it a ii,4 COM VEH El Ea 1 0
FIRST CONTACT 11 7_; _;__5 *IIYes.See Sidebar U1
Z Glendale Heights IL 60139 0 1 FL70413 IL 2026 REAR
TELEPHONE
IL D KL8CB6S97DC625322 Alliance ❑v ®N U2 r
ni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LAA-1118466-00 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 i v 0 Dv CIRCLE NUMBER(S) U1
yr 12 _ C
o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:-S COM•I sVEH See •Sidebar❑ ❑ C
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑y ❑N RDEF XI
EMS AGENCY PEDV PPA 1 PPL 1 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) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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m
/
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
Nu 1 ® 43 1 12,10 l2025 09 30 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 50
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
;, 2 0 28 11
t ! / ❑PM• ❑Construction *
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / El PM
o u ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
r 2 ❑ ARREST NAME AM
7 ! ! ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y
2 3 ❑ 1534-Santiago.Jorge 401 391-Jacobucci ! / ❑❑PM Workers present? ®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 truckrtrailer -<
` ` --: -' Lonpoommon?Pkwyflb 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
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
`---------•i0 } }} transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or
CO
` ` :-- - ...I. ,�j Not To Scale ' - 1* I• I• 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
for direct compensation(example:large van used for specific purpose):or O
L L____a____. Longcommon?Pkwy /B _ L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
' placarding(example:placards will be displayed on the vehicle). ;p
—I
CARRIER NAME Z
ADDRESS 0
w
o
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— -----"1 - USDOT NO. ILCC NO. rn
73
Source of above Z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 No 0 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
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE