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HomeMy WebLinkAbout2025-00079926 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII it ll 1111 10111100� �I�00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004076141 u, 1 U21 3 4 1 U116 U2 1 u1 1 U2 1 U, 1 U2 1 1 11 U1 11 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 2 VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00079926 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mWING ST Elgin ® ❑ RELATED ❑Y ®N 12 17 2025 ❑AM ❑YES El NO U1 -< PRIVATE mo /day/yr 03:40 ®PM FLOW CONDITION m I 0 ®!MI N E S © North State St COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR IR SLOW 6 (n Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n FOR DAMAGEDAREA(S) FRO T TOWED U1 01�0 / 13-UNDER CARRIAGE 1a , 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1 F 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 15-OTHER 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 ;il 6 4 COM VEH ❑ j$J 1 0 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7_;L _5 *Yves.See Sidebar Ut Z DIGGRR IL 2026 REAR TELEPHONE IL D 0 3GYFN H E34DS538187 Allstate ❑Y igi N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 932434282 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 c x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMV 0 NCv ❑DV CIRCLE NUMBER(S) U1 9 6 4 Ford F450 2019 00-NONE 11_-1 t2--_1 DUE TO CRASH ❑ !g► 21 73 o _ -y Yr 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 4 COM VEH ❑ ® u1 to II 5 H'_ FIRST CONTACT 6 Y__{_ -5 • C H McHenry IL 60050 0 1 174758H IL 2026 REAR IfYes.SeeSidebar 0 IL D 0 1 FD9X4GTXKEF10609 Amerisure Insurance ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Same CA21017620901 BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER®N u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 11 1 12,17 /2025 03 40 0 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 C) 2 ❑ 28 99 N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) 0 PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 -a, ARREST NAME / / ❑PM ' oN ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT r 2 El 25 NAMEAM c- 7 , / ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1515-BellEck.Stacy 501 391-Jacobucci , / ❑❑pM Workers present? ®N U2 25 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 A, _ } 1.c Has weighton):or more thanpound (example:truckortruckrtrarler 1. Hasa rating10,000 5 -I IINDICATE NORTH —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I IN - } (example:shuttle or charter bus):or C) 1 Not 7b Scene i, i � —' 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier i O I- I-----A---•-I ` - } } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or L -- -$- i limmin - t 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 Z CARRIER NAME Z -_ ADDRESS 0 T. rA O CITY/STATE/ZIP C) _ MOTOR CARR.ID ElInterstate ElIntrastate ' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 ‘I. - --1 USDOT NO. ILCC NO. C m XI Source of above z . 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 ❑ No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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 Black Red 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE