HomeMy WebLinkAbout2025-00078713 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO0411215!
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00078713 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
FULTON ST El In02:16
® ❑ RELATED ®Y 0 N 12 11 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W VILLA ST COUNTY PROPERTY :IY ® N DOORING Ely #OF MOTOR El SLOW fA
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROf�tr_ TOWED U1 0
NAME(LAST,FIRST,M) Unknown.2025-00078713 mo ! ! yr Jeep(after 1968)Ind Cherokee 2011 00-NONE Q Oi 0DUE TO CRASH ® 0
13-UNDER CARRIAGE 16 • 2 FIRE 0 NIC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2
9 9 SYSTEM IN O ENGAGED O 15-OTHER 9 16.TOP 3 0
_
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & IL 6 '�.4 C.OM VEH 0 j$J 4 0
I— 0 9 0 FIRST CONTACT 12 T_; _-5 *If Yes.See Sidebar U1
Z DL4809F IL 2025 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED
1J4RR4GT6BC551632 Unknown ❑Y ®N U2 Mr
SI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Kennedy Motors Unknown 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
r D YOND
N ( X
0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 - C
o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 *Distraction Value 9 -
-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT i -d:=5 •
CIO e1sVEHSee Sidebar❑ ❑ U1 C
CO
F` pEAR` C
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (0OB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
/
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 3 12!11 l2025 02 16 ®❑pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 70
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
;, 2 ❑ 38 3 28 18
t ! ! ❑PM, ❑Construction >F
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME / / ID PM '
o N1 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit 30
y
SLMT
t 2 ARREST NAME AM
! r ❑❑PM El Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME Y
-2 3 0 ❑AM Workers present? ❑
1505-Caliendo.Anthony 301 ! ! ❑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- }-----I-- --' / INDICATE NORTHcombination):or
NDI p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
/ _ (example:shuttle or charter bus):or
X
LA 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier- } } } transporting employees In the course of their employment(example:employeeI transporter-usually a van Type vehicle or passenger car):orC
1/',
. 4. Isusedordesi natedtotrans rtbeen9and 15} } } g po passengers,for direct compensation(example:large van used for specific purpose):or} } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires IIIplacarding(example:placards will be displayed on the vehicle). mCARRIER NAME fr,& 0
— — — — — ADDRESS w
C)
-1 A r CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
NV 7bfd--� ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. If Yes,Name on placard O
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
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE