HomeMy WebLinkAbout2025-00009128 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
01101100 VI III .1100111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003723101
u, 1 U21 1 1 1 U, 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY [8]OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00009128 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 02 11 2025 ®AM ❑YES ®NO U1 -<
S RANDALL RD Elgin mo /day/yr 09:53 ❑PM FLOW CONDITION m
75 COUNTY PROPERTY ❑y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
® ®!MI N E O W Weld Rd WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
1 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Boeckh, Donna.J. mo1 /
13-UNDER CARRIAGE 10 , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 14 U2 4 rn
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL 6 1,.4 COM VEH 0 Ej 1 0
H 1- HAMPSHIRE IL 60140 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.See Sidebar U1
ZA356082 IL 2025 REAR
TELEPHONE
IL D 2FMDK38C08BA40175 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0289797SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 3 2 73
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 Ncv ❑Dv CIRCLE NUMBER(S) U1
1960 Chevrolet Malibu 2015 00-NONE 11_"j Q�,-_, DUE TO CRASH rg 2 x
o r 13-UNDER CARRIAGE 10) I 2 FIRE ❑ El U2 C
M 2 8 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 3
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 i 4 COM VEH ❑ ® Ut W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -II 6 .'_
FIRST CONTACT 6 Y__{_0 -s •If Yes,See Sidebar
Z Chicago IL 60707 0 1 0 Q761608 IL 2025 REAR 0 C
Z
IL D 1 G 11 B5SL2FF246095 State Farm ❑Y ®N RDEF .73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2395560SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N 3 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 ❑Y U2 Z
N 1 ® 11 1 21 , 11 ,025 09 53 ®❑pM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0
1
2 0 28 15 , , ❑PM ❑Construction *
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Boeckh, Donna,J. 11-601 298001196W r r El PM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
2 ❑ 11 1 ARREST NAME AM
Ti 1 r ❑❑pM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 50
298-Lopez, Mirko 800 272-Bajak , / ❑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 -<
c ` '' -' r INDICATE NORTH combination):or .Z-1
OBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N� _ ,. ,. (example:shuttle or charter bus):or
Not 7o Scale j 3. Is designed to car 15 or fewer passengers and operated a contract carrier O
_ i - } } } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
I Pe ( P 9 Pe or
< <____a____1 ..�. - - nl } } } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
// m
— —/ 1 C.
1 placarding(example:placards will be displayed on the vehicle). >
r r -:- '.. \ - Randall?Rd. i' _�
CARRIER NAME Z
ADDRESS 0
C
CITY/STATE/ZIP no
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Blue.Dark
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Owners Residence . 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