HomeMy WebLinkAbout2025-00004982 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 0 11000100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003708515
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00004982 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m® ❑ RELATED PRIVATE ❑Y ®N 01 23 2025 la— ❑YES ®NO U1 -<
S RANDALL RD Elgin mo /day/yr 03:35 ®PM FLOW CONDITION III
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®20 ®!MI O E S W Foothill Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n
0 3 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 6 m
M 2 SY 15-OTHER
8 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 4 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i 4 COM VEH 0 j$J 1 0
HuntleyIL 60142 B 1 0 FIRST CONTACT 11 7_: __5 *rives.SeeSidebar U1
Z DP48399 IL 2025 REAR
TELEPHONE
IL D 0 KM H D84LF3LU895123 Country Financial ❑v Il N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Elgin Fire 99 9 Mahon. Lisa. L. P010411264 1 I—
t HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 Ncv 0 DV CIRCLE NUMBER(S) U1
'1 9 6 4 Jeep(after 19681�rokee 2019 00-NONE 'o,� t2 (,-2 DUE TO CRASH ® U2 2 C
o Yr 13-UNDER CARRIAGEFIRE 0
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 5 7 —_,SOS •(ryes,See SidebarC
ELGIN IL 60123 0 1 0 EM73593 IL 2025 I 0
IL D 0 1 C4PJLDB2KD434070 Progressive ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 988205188 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 01 ,23 ,2025 04 34 0 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)
v 2 0 41 99 01,23 ,2025 03 38 ®PM 0 Construction >F
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
-a, ARREST NAME Mahon. Ethan. M. 11-601 S1544-000068 01,23 r2025 03 47 Igi pM CITATIONS ISSUED PENDING SLMT
1 ® 11 1 ❑ • Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME Ely
t 2 El ARREST NAME 01 123 r2025 04 35 ®PM 0 Unknown work zone type U1 50 0 AM
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
1544-Solis,Yulissa 801 334-Fries 02 ,25,2025 01 30 El NI ®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 truckrtrailer -<
i- }---_r----; \ - combination):or —I
i INDICATE NORTH p1
\ -.-� BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L \ \ Nor,a etiwsf } (example:shuttle or charter bus):or 0
`- .\\ \\ - transporting employees ol0 aees15 or fewer ln the course��rye ersnantlyment example contract
empk)yeeder X
- I. I- po ng p Y employment
transporter-usually a van type vehicle or passenger car):or w
L L.___a____� �\ - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
I. } } for direct compensation(example:large van used for speific purose):or
•
L L____a____. ttfko - 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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\ pWcartling(example:placards will be displayed on the vehicle). X/
i \ D
i \\ N CARRIER NAME
i
i/ \\ \\ ADDRESS
•
CITY/STATE/ZIP 0
0
- MOTOR CARR.ID 0 Interstate El Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --• - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
XI
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 M
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
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Mies/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE