HomeMy WebLinkAbout2025-00003494 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111
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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 ®NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
❑AMENDED YR 202512025-00003494 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ®Y 0 N 01 16 2025 ®AM ❑YES ®NO U1
S RANDALL RD Elgin11:27
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
�r,0 !MI N E S W HO S Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
IXI ® pp Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
18: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
1 0 !
13-UNDER CARRIAGE 1a , 2 FIRE 0 lE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
El N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;A 6 I,.4 COM VEH 0 181 1 0
FIRST CONTACT 12 7_:—, _5 *Irves.See Sidebar Ut
V Z Streamwood IL 60107 0 1 N852773 IL 2025 REAR
M TELEPHONE
IL D JA4AP3AU 1 BZ003422 All State ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Ruiz. Rodrigo 811756148 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 7]
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
!1 9 6 5 Mercedes-Ber1Z300 2014 00-NONE 11-1 12'"_, DUE TO CRASH ❑ C 2
o yr 13-UNDERCARRIAGE 101 2 FIRE ❑ ® U2 C
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F 2 4 ❑Y ❑ El
IN ENGAGED 15-OTHER 9 16•TOP 3 0
N UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
i-II 5 �' 4 COM VEH 0 ® U1 W
FIRST CONTACT 6 Y__{_O ._5 •IfYes,See Sidebar C— Batavia IL 60510 C 1 0 Z324708 IL 2025 REAR 0 Si)
IL D WDDGF8AB7EA910795 Safeco ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Same Z5155050 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)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 01 (16 l2025 01 00 ®PM in a Work Zone? ®N DIRP D
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
Fic 2 ❑ 41 99
N 1 3 0 ❑CITATIONS ISSUED 0 PENDING , , ❑PM• ❑Construction >E
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a ARREST NAME / / ❑PM '
o, N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SIMT
50
t 2 0 ARREST NAME AM
7 ( r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 50
540-Dykema.Tracy 275-Engelke , ( ❑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
Not To Scale ADDITIONAL UNITS FORMS.
r ----r••--, 0 - ; 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---.r__--; I. INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L i I I I _�fi7M1b0�lldl _ } rr (example:shuttle or charter bus):or
I- designed to carry15 or fewer passengers and operated I a contract carrier O
}-----I- --i ifk�'e�7t07I - } } } transporting employee � �In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - - _ _ - } } } g po pafc rs, or the driver,
for direct compensation(example:large van used for specific purpose):or 0
i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a t placarding(example:placards will be isplayed on the vehicle).
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I I I x,
_ CARRIER NAME Z
ADDRESS
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CITY/STATE/ZIP n
I I
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0O
I. --- '-4 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
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: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE