HomeMy WebLinkAbout2025-00009452 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 VI 10 00 110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003728541
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 3
VEHICLE/PROPERTY ®OVER 31,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00009452 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
1425 N RANDALL RD Elgin12:37
® ❑ RELATED ®Y 0 N 02 12 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
I83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uMv 0 IiCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRO 1 TOWED U1 0
Macrito. Michelle.A. 1 0 /
yr 13-UNDER CARRIAGE 10.I , 2 FIRE 0 NI <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 M
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 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 s, ii_6 I,.4 COM VEH 0 Ej 1 0
F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1
V Z Chicago IL 60506 0 1 EB20426 IL 2025 REAR
TELEPHONE
IL D 3CZRU6H55MM712984 Progressive ❑Y ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 986397466 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 XI
N DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWESmi 0 v 0 v ❑Dv
yr
'1 9 8 1 Chevrolet Malibu 2010' 00-NONE ,�_-1 12..-_, DUETO CRASH ❑ 0 2
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
il F 2 4 ❑Y ❑ El
IN ENGAGED 15-OTHER 9 16•TOP
3 3 X
N UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value
POINT OF s i 4 COM VEH D ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 7 -�IOS •If Yes,See Sidebar C
Prospect Heights IL 600070 C 1 EY648375 IL 2025 I 0
Z
IL D 1G1ZB5EB7AF119342 United Security Ins Co ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same U LS 1049013-00 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
{UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
2 3 1 0 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 1 02,12 l2025 12 37 ®PM in a Work Zone? ®N DIRP co
1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 28 99 , , ❑PM• ❑Construction
Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-, 1 ® 11 1 ARREST NAME Macrito. Michelle.A. 11-601 414-1010 / / El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
❑ 40
F 2 El ARREST NAME AM
7 1 r ❑PM El Unknown work zone type U1
2 2 3 ID
ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 40
414-Lara. Saul 901 272-Bajak 03 , 18,2025 09 00 ❑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
r r ADDITIONAL UNITS FORMS.
r ----r••--, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I
'i 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
;.---_r----; I ( combination)or
INDICATE NORTH C
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
- Not To Scale I } (example:shuttle or charter bus):or
X
, iI -�
I- I- --I-- } 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or coC
L L.___a__ N - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)= for direct compensation(example:large van used for specific purpose):or
L L--_-a-___� ...1 �~ \ - t i. i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
- —I
CARRIER NAME Z
I of ADDRESS O
w
CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other 0
--
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 g
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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE