HomeMy WebLinkAbout2025-00079887 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets IIIIII 11 IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00079887 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ®Y ❑N 12 17 2025 ❑AM ❑YES ®NO U1 —<
S RANDALL RD 1 PRIVATE DR Elgin mo /day/yr 12:02 ®PM FLOW CONDITION M
2350q0!MI N EON Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
(g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
0 7 /
yr 13-UNDER CARRIAGE NI
101 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 r<rl
M SY❑Y ❑SNEM®UNK VEH. 9 ATCRASHD 9 99-UUNKNOWN 15-OTHER 9 i6•TOP 3 `DistractionVatuc 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 7 POINT OF ij a 4 COM VEH 0 Ea 1 0
F. FIRST CONTACT 00 _;, ,__5 *IIYes.SeeSidebar U1
. Z ST CHARLES IL 60175 0 AX17693 IL 2026 REAR
TELEPHONE
IL D 4M2EU38E88UJ13432 West Bend Mutual Ins Co ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Williams.Sean, M. H H D8612675 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
L RESPONDER
0 ( 73
m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 MAV 0 NCv ❑ CIRCLE NUMBER(S) U1
DV
/1 9 6 3 Nissan Armada 2026 00-NONE i1_"j Qr,-_, DUE TO CRASH ❑ 2 x
oy Yr 13-UNDER CARRIAGE 10( ) 2 FIRE 0 ® U2 C
F Y SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑ ❑ ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0
POINT OF s-.;,�.i_4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •If Yes.See Sidebar
1= ELGIN IL 60124 0 BURKEXC IL 2026 I 0 C
IL D JN8AY3BB9T9120137 County Financial ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same AB2045040 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPONDER Y u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 07 /
/ / UI 2 :A
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 ® 11 4 12/17 /2025 12 02 ®PM AM in a Work Zone? ®N DIRP D
co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1
0
2 ❑ 9 25 41 / / ❑PM ❑Construction >F
R 3 ❑ $ 8
I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
o ® 11 4 ARREST NAME Williams.Theodore, R. 11-305-A 410000772 / / ❑PM SLMT
S' N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM
t 2 El ARREST NAME / / ❑❑PM 0 Unknown work zone type U1 50
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 50
410-DeLeon,Jessica 801 01 /20/2026 01 30 ®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 Bator vehicle used to transport passengers or property and: Z
c ,. r _, I ( _ } I combination):weight rating more than 10,000 pounds(example:truck or truck trailer
-<
NDICATE NORTH
I s ,'.," "'""'" BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
z;;°I I } (example:shuttle or charter bus):or 0
I i 3. Is designed t carry5 fewerpassengersoperated contractcarrier` A � � esig o 1 or and pe atetl by a ne i O
,iiiwo,, I - } } } transporting employees in the course of their employment(example:employee X
- - -
6 transporter-usually a van type vehicle or passenger car):or CO
L -----}----; 4p ' I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, (C/)
— — —
� for direct compensation(example:large van used for specific purpose):or O
` -D
L L____a____. - tl. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
Nor Tb SNb
I• I 14 ` placarding(example:placards will be displayed on the vehicle). XI
D
I ( CARRIER NAME Z
%i- _ ADDRESS D
CITY/STATE/ZIP n
IIi._ MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I ‘I. -- - --, _Y_ __ I I ' USDOT NO. ILCC NO. 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 0 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE