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HomeMy WebLinkAbout2025-00003588 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III II IIIIII UHI II IIIII110 fbI )III DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036S431/3 u, 1 U21 1 1 1 U1 4 U2 1 U1 1 U2 1 U1 1 U2 1 5 14 U1 1 U2 1 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' 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 0 AMENDED YR 202512025-00003588 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ❑Y ®N 01 17 2025 ®AM El YES ®NO U1 -< N RANDALL RD Elgin 02:06 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m �90 !MI N E S W Higgins Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn 02gg Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4�TOWED U1 0 mo Miranda. Dereck. N. Honda Civic 2022 00-NONE ©1 >2 �/OUETOCRASH ® ❑ NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10. • 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 8 ❑Y ®SNEM❑ n is-OTHER UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a 4 COM VEH 0 )0 1 0 F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1 Z WEST DUNDEE IL 60118 0 1 DG61300 IL 2025 REAR TELEPHONE IL D 2HGFE2F58NH571511 State Farm ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Miranda.Joel.G. 0953206SFP13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 ou g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEOAL ❑EWES 0 '1 9 8 0 Toyota Camry 2016 00-NONE 0.. Q!•-O DUE TO CRASH 0 ❑ 2 x o y Yr 13-UNDER CARRIAGE 10) I 2 FIRE ❑ ® U2 C M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value U1 2 POINT OF 8 i1�I 4 COM VEH ❑ ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .5 •)ryes.See Sidebar — Lake in the Hills IL 60156 C 1 0 BM87391 IL 2025 REAR 0 C IL D 4T1 BF1 FK9GU589280 Progressive ❑Y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 954169535 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Sherman RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 01 / ' D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 01 !17 /2025 02 06 ®❑AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 453. 2 ❑ 28 18 01!17 /2025 02 06 ❑PM ❑Constrtict on * R O ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 3 ®AM ❑Maintenance U2 o ® 11 1 ARREST NAME Miranda. Dereck. N. 11-601 498001143 01/17/2025 02 15 ❑pM SLMT ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• • El Utility t 2 El ARREST NAME Miranda. Dereck. N. 11-601-B 498001142 01/17 /2025 03 16 MPM El Unknown work zone type U1 50 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 498-Johnson.Andrew 502 02 /25/2025 09 00 0 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 i- ( r 0 f 1.c Hasa rratingmore than pounds(example:truck or truck trader 1. Hasa weight 10 000 -< INDICATE NORTH tan)o A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - } (example:shuttle or charter bus):or 0 Not To Scale 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 - <_-- }-Jr----• } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L }-----}----; - } } 1. •4. Is used or designated to transport between 9 and 1 passen rs,including the driver, C ii for direct compensation(example:large van used fors cific purpose):orOL L____a____. _ t i. i i ._ 5. Is an vehicle used to transport any hazardous material(HAZMAT)thatrequires 'D placarding(example:placards will be displayed on the vehicle). XI —I CARRIER NAME Z eavuruton?Dr ADDRESS 0 0 CITY/STATE/ZIP 5 i i i i , n , r - MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- 1 USDOT NO. ILCC NO. rn PCI Source of above Z . own tank)? 0 Yes 0 No 0 Unknown D Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0 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 O TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 z ri TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black White u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE