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HomeMy WebLinkAbout2025-00004305 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 11111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037OO903 u, 1 U21 3 4 1 U1 7 U2 1 U, 1 1_12 1 U1 1 U2 1 1 11 U1 1 U211 *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 ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00004305 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n S RANDALL RD Elgin02:50 ® ❑ RELATED ®Y 0 N 01 20 2025 12— ❑YES El NO U1 —< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION Ill FT N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 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 n FOR DAMAGEDAREA(S) R2'ONt�TOWED U1 Q Russell.Jordan. D. 1 2 / yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M I 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH 0 Ea 1 O H F. Berwyn IL 60402 0 1 0 FIRST CONTACT 12 7 . _5 *Ifves.SeeSidebar U1 Z rwYV755303 IL 2025 TELEPHONE IL D 0 1 B3HB28BX7D320641 AAA ❑y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same AUT701558500 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 KKv 0 DV !1 9 4 9 Toyota Corolla 2020' 00-NONE 'o,I t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE iI F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistracl on Value 0 POINT OF 8 i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QOS •It Yes.See Sidebar C Galena IL 61036 0 1 0 P639304 IL 2025aR0 Si) IL D 0 JTDFPRAE1 LJ079651 State Farm ❑y ®N RDEF XJ EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 0904214-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 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 1 01 ,20 /2025 02 50 ®PM 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 � 0 2 03 28 ) ! 0 PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a, ARREST NAME / / El PM ' 1 El1 11 1 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 t 2 El ARREST NAME 01+20 /2025 02 50 ®PM El Unknown work zone type U1 300 AM n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 488-Ramos.Arely 702 334-Fries , ! ❑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 ____r____; I I _ combination): r more than pounds(example:truck ortruckrtrarler 1. Has a weight rating10 000 -< INDICATE NORTH o p3 LBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ .:.. -:. j d I I (example:shuttle or charter bus):or 0 , 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O - ----------•i ` } I.- } transporting employees in the course of their employment(example:employee Hcep.7Ra. transporter-usually a van type vehicle or passenger car):or w L L.___a____� — 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y I. } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L i — — — — t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). XI —1 © CARRIER NAME Z - __ 1 ADDRESS0 D 1-0 w Not To ScaleI Im o CITY/STATE/ZIP g � - i. i. i. 4. MOTOR ❑ Interstate 0 Intrastate 1 I r 1 I I '_ ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- ----- - 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 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 iD No 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gold Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. _Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE