HomeMy WebLinkAbout2025-00079320 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111 0110 11
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 0 0639
u, 9 U29 3 4 1 U199 U2 1 u,99 u2 1 u,99 U2 1 3 10 u, 6 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 El ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00079320 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
N STATE ST Elgin05:01
® ❑ RELATED ®Y 0 N 12 13 2025 ❑AM ❑YES IX]NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W WEST RIVER RD COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROM TOWED U1 0
Unknown,0. Unknown Unknown 00-NONE ,, • 12 0OUETOCRASH ❑
NAME(LAST,FIRST.M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I�B �i,_ 1 00
0 9 FIRST CONTACT 1 7_; _5 *irves.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 I—
t HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
�{ DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 1Av 0 NCv 0 DV
/1 9 4 7 Subaru Forrester 2023 00-NONE O, . 12..-_, DUE TO CRASH ❑ 2 73
o 13-UNDER CARRIAGE 10� 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y ON ❑UNK VEH. AT CRASH 99-UNKNOWN •0istracton Value 0
POINT OF 8 i 4 C.OM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:L- C
FIRST CONTACT 11 7 _5 •If Yes.See Sidebar
Huntley IL 60142 0 1 0 A454456 IL 2023 REAR 0 N
IL D JF2SKAEC8PH468440 Progressive Insurance ❑v 0 N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
JP Morgan Chase Bank 985952078 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)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U2 0
996
m
##occs y
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DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 9 12,14 l2025 10 08 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 20
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 06 15
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
—a, ARREST NAME / / ❑PM '
o u ® 11 4 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
45
t 2 ARREST NAME AM
7 1 r O PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 45
538-Ciesielczyk, Matthew 501 r / ❑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
p3
tillBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - } (example:shuttle or charter bus):or C
. I ` ,_, I Not To Scale 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
` es pa 9 pe by
} A i `
\ } } } transporting employees in the course of their employment(example:employee X
i_ <----------1 I Y I - } } } •transporter sed or des gnated to transport between 9 and r 1 passengers,including the dryer,
03
C
for direct compensation(example:large van used fors specific purpose):or O
D
L L___-a..... I 5 Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
rn
V / placarding(example:placards will be displayed on the vehicle). ;p
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g' IMetrrrnYl CARRIER NAME
_ _\
\ _ ADDRESS D
I =
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __. - USDOT NO. ILCC NO. 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 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes iO 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
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Green
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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