HomeMy WebLinkAbout2025-00082209 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00082209 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 �I
E CHICAGO ST Elgin08:09
® ❑ RELATED 181 Y 0 N 12 31 2025 ❑AM ❑YES E)NO U1
_ _ g PRIVATE mo /day /yr ®PM FLOW CONDITION III
FT!MI N E S W CENTER ST COUNTY PROPERTY El ® N DOORING ®y #OF MOTOR 0 SLOW 99 Cl)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST❑N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS N PED ❑PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRONfr TOWED U1 0
Schif. Maxwell.C. 1 0 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 0 <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rn
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;i�B 4 COM VEH 0 0 1 0
c Z ELGIN IL 60120 B 1 0 FIRST CONTACT 15 7 ; _5 *If Yes.See Sidebar U1
REAR
TELEPHONE
IL NA ❑Y ®N U2 I''I
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Elgin Fire 1 52 2 NA 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
Provena St.Joseph ❑Y ❑ N 98 .41
0
E{ DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row 0 NOV 0 Dv CIRCLE NUMBER(S) U1
yr Jeep(after 198;i)ind Cherokee 2023 00-NONE 0.. Q!'-O DUE TO CRASH ❑ ® 99 xi
...
13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 0
a 9 9 ❑Y ❑
i NDUNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 1:, COM VEH ❑ ® U1 W
FIRST CONTACT 11 7� , _5 •(ryes.See Sidebar
~ 0 9 0 FL13838 IL 2026 REAR 9 C
M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0
1C4RJKBG8P8806674 Unknown ®Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 52 2 Foster.Allen. P. Unknown BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
UI ' D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 4 12,31 l2025 08 56 ®AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0
Eri 2 2 18 12,31 /2025 08 10 PM
® • 0 Construction >F
Z 3 0 ['CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
-a ARREST NAME 1 2/31 /2025 08 14 0 pM '
SECTION CITATION NO. ROAD CLEARANCE TIME
1 1 2 4 ❑CITATIONS ISSUED ❑PENDING Utilit SLMT
o, N ® 0 y
®AM U1
r 2 0 ARREST NAME 12/31 /2025 08 09 PM 0 Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
1543-Sturgeon. Kyle too 320-Cox , / ❑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 truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or —I
i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} r r ,. (example:shuttle or charter bus):or X
N 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
}} } transporting employees in the course of their employment(example:employee X
®
Not To Scale 1 transporter-usually a van type vehicle or passenger car):or w
__ _—1 exnrawam•� .w� " _ 4. Is used or designated to transport between 9 and 15 passengers,including cci'11 • } } } g po passen rs,includi the dryer,
for direct compensation(example:large van used for specific purpose):or O
1 L I-____a____.I t } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
- — — — — placarding(example:placards will be displayed on the vehicle). XI
—1
r CARRIER NAME Z
I I _ ADDRESS
V)
CITY/STATE/ZIP
I
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- ----1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
T.
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE