HomeMy WebLinkAbout2025-00009946 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II OHI
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00009946 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 02 14 2025 ❑AM ❑YES ®NO U1 -<
N RANDALL RD Elgin mo /day/yr 06:15 ®PM FLOW CONDITION m
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05 COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 Cl)
® FT/� N E OS W I-9O WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 06 n
0 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 06 I<n
F 2 SY n 15-OTHER
4 ❑Y ®SNE❑UNK VEH. AT CRASIN n H 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il S 4 COM VEH 0 0 1 C)
F. FIRST CONTACT 12 7__,--_,__S *IIYes.See Sidebar U1 0
Z AURORA IL 60505 0 1 DZ62340 IL 2025 REAR
TELEPHONE
IL D JN8AS5MV9DW638630 ENCOMPASS INSURANCE ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 2025935325 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
'1 9 8 5 Nissan Sentra 2013 00-NONE 'o t2 ( 2 FIRE DUE o CRASH ® U2 2 cXj
13-UNDER CARRIAGE El
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraebon Value 9 0
POINT OF S i 4 C.OM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 O7 :----,OS •ITYesSeeSidebar C
Z ALGONQUIN IL 60102 0 1 ACHAMPS IL 2025aR 0 N
D
IL D 3N1AB7AP3DL724361 STATE FARM ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 1423858-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 0 Y U2 Z
N 1 ® 11 1 02(14 /2025 06 15 ®AM 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 C)
0 2 ❑ 03 28 ( ( 0 PM ❑Construction *
N 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a RAMIREZ. MARIA.C. 11-601 1506-363 / ! PM "
-, ARREST NAME ❑
oN ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
T 2 ❑ 45
AM
7 ❑❑ ❑
PM Unknown work zone type U1
ARREST NAME ( 1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1506-Nunez. Maria 502 03 ( 11 (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
GI . ADDITIONAL UNITS FORMS.
r r ,
A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r Not To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
___ LI combination):or -I
` -' -' I • INDICATE NORTH
fl BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Aso - } (example:shuttle or charter bus):or 0
X
L A 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
transporter-usually a van type vehicle or passenger car):or w
' . 4. Is used or designated to transport between 9 and 15 passengers,including (I)
-- -- } } } g po passen rs,includi the driver,
1 I / for direct compensation(example:large van used for specific purpose):or O
i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
L 1 placarding(example:placards will be displayed on the vehicle).
H
CARRIER NAME Z
.o.r. - ADDRESS O
t
CITY/STATE/ZIP 0
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I TI II I ❑ Not in Comm./Govt. ❑
Not in Comm./Other
0
I I
• USDOT NO. ILCC NO. C
m
XI
Source of above z
. 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
71
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
Black Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE