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HomeMy WebLinkAbout2025-00078984 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 11 II IOU U Ill�Ill0011011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004068.93 u, 1 U21 3 4 1 U1 3 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 10 u, 1 U2 3 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash El AMENDED YR 202512025-00078984 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �l SUMMIT ST El11:54 ® ❑ RELATED ' V 0 N 12 12 2025 ®AM ❑YES El NO U1 _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION MFTlMI N E S W WAVERLY DR COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OFMOTOR El SLOW 15 u) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 6 ! yr g Dodge Ram 1500(pickup) 2022 00-NONE ©, 12 , DUE TO CRASH ® ❑ 13-UNDER CARRIAGE 10 1 2 FIRE ❑ al < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 1T1 F 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 5 ALGN = ❑ El N ID VEH. AT CRASH 99-UNKNOWN `Distraction Vatuc r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 ii,4 COM VEH El Ea 10 Z ELGIN IL 60120 0 1 3750622B IL FIRST CONTACT 11 7_; __s uYes.See Sidebar u1 0 REAR TELEPHONE IL D 1 C6SRFJT4NN378995 Rockford Mutual ❑Y Il N U2 Si . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same PA000059419-013 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused El El 2 c m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑!My 0 Ncv ❑DV !1 9$2 Cadillac Escalade 2015 00-NONE 1oII 12 :_y FIRE DUE D CRASH ® U2 2 C o 13-UNDER CARRIAGE III Po F 2 8 SYSTEM IN ENGAGED 15-OTHER 9.1,6-TOPO3 0 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistraglon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 I.'( 4 COM VEH ❑ ® U1 CO FIRST CONTACT 3 7-'_, _5 •Iryes,See Sidebar H ELGIN IL 60120 B 1 AQ18085 IL 2022 REAR 0 N IL D 1 GYS4CKJ3FR274683 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 811468039 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Sherman RESPONDER u1 = )UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)r(TELEPHONE) (EMS) (HOSPITAL) U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 12,12 l2025 11 54 ®❑pM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 ❑ 25 41 , , ❑PM ❑Construction * , o Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 8 o1 ® 11 4 ARREST NAME Weaver. Brenda. L. 11-305-A 346000268 ! ! ❑PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 35 T 2 ARREST NAME AM 7 El r ❑❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 345-Gomoll.Geoffrey 201 01 , 13,2026 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 i- ----r----1 I 0 - f combination):. Has or more than pounds(example:truck or truckrtrarler -< 1. Has a weight rating10 000 INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ II - i.i. e. r (example:shuttle or charter bus):or 0 I3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I-. -A----1 ` } } } transporting employees In the course of their employment(example:employee rter- y a van type vehicle or co L L.___a__ J 4alsuosedordesllnatedto transport between9a dr15passengers,includingthedriver. C } } } for direct compensation(example:large van used for speific purose):or L L____a....� �' au aee.r L _ 5 Is an anyvehicle used to transport hazardous material(HAZMAT)that requires m T `�1 placarding(example:placards will be isplayed on the vehicle). XI —1 CARRIER NAME Z ADDRESS 0I C I CITY/STATE/ZIP O .0 Not To Scalei.I _ MOTOR CARR.ID ❑ Interstate 0 Intrastate I I T I t ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 � "Y""1 USDOT NO. ILCC NO. C m XI Source of above z . 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 ❑ 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 Gray Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. Arties/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE