HomeMy WebLinkAbout2025-00080694 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 1111 100 IV
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004082582
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2O25-00080694 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ❑Y ®N 12 22 2025 ❑AM ❑YES ®NO U1
N STATE ST Elgin 01:11
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
0 /MI N E S W East Chicago St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® g Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g)DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C)
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 OO r<n
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I�6 li,_ 1
1 0 9 FIRST CONTACT 99 7 ; _ COM VEH ❑ Ea 5 *IIYes.See&debar U1
0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER 0
W 0 DRIVER I} PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 Dv
yr 13-UNDER CARRIAGE 11 112 2 FIRE El ® U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 (21 SPDR 0
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I C I 4 COM VEH D ® Ut CO
F,,, FIRST CONTACT 9 7 i I�.5 •• •Iryes,See Sidebar C
CM26292 IL 2026 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 3N 1 AB7APOJY263165 American Property&Casua ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same PAI L00009873 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPOND
fg N U1 =
Y
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 1 0 3 / M 1 3 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 12/22 /2025 01 11 ®PM AM in a Work Zone? ®N DIRP D
co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 30 15
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + / 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
2
—a, ARREST NAME / / ID PM '
1 ® 1 1 1 UtilitySLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
t 2 El ARREST NAME 12/22 /2025 01 11 ®PM El Unknown work zone type U1 05
, AM
T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - El Am Workers present? ❑Y 05
1561 Sarovic• Mirko sot / ❑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.
Not To Sags
-<
r ----r••--, ■ ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Q•N II ■ 01. Has a weight rating more than 10,000 pounds{example:truck or truck trailer
c ` -' -' . r INDICATE NORTH combination):or .Z-1
■■■■■■■■■■I■ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
. _ (example:shuttle or charter bus):or
' ■ r r r °
< ------;----; : transporting employened to es inthe course passengers5 or fewer thir emplod yment example:employeener X
y a van type
L L.___a____� �sedordrter- �llnatedto transport betweeicle or n9 and r15r) ssen rs,induding[hedriver,
C
1_B ) I. ' } } for direct compensation(examp large van used for specific purpose):or 0
L 1 L t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
A
- _I
is AI:- CARRIER NAME Z
-- (!:!r' --■ ADDRESS O
0
CITY/STATE/ZIP
_ i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
■ USDOT NO. ❑ Not in Comm./Govt.NO Not in Comm./Other 0
■ ILCC m
73
Source of above z
. MCS ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE