HomeMy WebLinkAbout2025-00082165 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004097110
u, 1 U29 1 1 2 U116 U299 U, 1 1_12 U, 1 U2 1 4 9 U1 1 U221 *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 El OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00082165 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m188 S GIFFORD ST El 04:53
® ❑ RELATED ❑Y ®N 12 31 2025 12,— ❑YES El NO U1 -<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv p!Cy 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
0 8 !
yr
Edwards.Stephen. B. Nissan Murano 2013 00-NONE ,, • 12 , DUE TOCRASH ❑ VI
13-UNDER CARRIAGE FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0 U2 02 m
M 2 4 ❑Y ® 15-OTHER
SYSTEM
❑LINK VEH. 0 AT CRASH 0 99-UNKNOWN 9 16-TOP() ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 �I COM VEH 0 j$J 1 n
F. FIRST CONTACT 1 7 _---I-_5 *II Yes.See Sidebar U1 0
Z SOUTH ELG I N IL 60177 0 1 0 V293315 IL 2026 iisui
TELEPHONE
IL D 0 JN8AZ1 MW1 DW309014 Erie Insurance ®Y 0 N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same Q052117327 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused 0 Y ® N 2 0
p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr Chrysler 300 2015 00-NONE „ 12 "_, DUE TO CRASH ❑ ® 1 ,'a
o 13-UNDER CARRIAGE FIRE 0 ® U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR n
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 0
POINT OF s I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 i'._ C.OM VEH D ® CO
F,,, FIRST CONTACT 9 7 _,___5 •If Yes.See Sidebar
FJ31949 IL 2026 REAR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2C3CCAAG9FH796746 American Property&Casua ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same PAIL00010144 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPOND❑Y 0N Ui =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
u 1 ® 18 1 12,31 l2025 04 53 ®AM in a Work Zone? ®N DIRP 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 C)
2 ❑ 20 15 , ) ❑PM ❑Construction *
o
R 3 ❑ $I CITATIONS ISSUED El PENDING
PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Edwards.Stephen. B. 11-708 1561-000175 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
D AM
t 2 ❑ ARREST NAME 12)31 12025 04 53 ®PM El Unknown work zone type U1 25
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1561-Saroyic, Mirko 401 320-Cox 02 ,03,2026 09 00 ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} }-- -i-- --; } } } ,- -, , ; ; , ; ( combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' 1 , } (example:shuttle or charter bus):or
X
3. Is
L L.___A_._ 1 ____... . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_- , li < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____4 L L L ,.___-4_ ; l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 0
T.
, n
, CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number m
m
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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 Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 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