HomeMy WebLinkAbout2025-00012957 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M 11111111 1100 0111 1111010
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003742014
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ® B Injury and for Tow Due To Crash YR 202512025-00012957 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
1425 N RANDALL RD El03:45
® ❑ RELATED ❑Y ®N 02 27 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 17 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EDUCE ❑NOV ❑!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
0 3 FOR DAMAGEDAREA(S) FROr'tf TOWED U1 O
Kia Motors CO uI 201 5 -NONE 11' 7:1 DUE TO CRASH 0/ yr
13-UNDER CARRIAGE 10 i ,2 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 �i 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *Il ves.See Sidebar Ut
Z DZ75139 IL 2025 REAR
TELEPHONE
IL D 0 KN DJX3A5XF7112154 Farmers Insurance ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 531761829 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
❑ DRIVER 0 PARKED 0 DRIVERLESS 0 PED N PEDAL 0 EWES 0 NMV 0 NCV 0 DV
yr ,a' ,2 ( 2 FIRE ❑ ® U2 C
Ti 13-UNDER CARRIAGE
M 5 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN •0istraetlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-�1. 6 j1:_4 COM VEH D ® U1 CO
FIRST CONTACT 4 7�'� �_5 •(ryes.See Sidebar C
H ELGINAR 0 Si)
M IL 60120 B 2 8
IL D 0 ❑Y 0 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 64 1 Same SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
uN 1 ® 13 1 02,27 r2025 03 45 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)
2 ❑ 2 99 02,27 ,2025 03 46 PM
® • ❑Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
—a, ARREST NAME 02r 27 r2025 03 54 ®pM '
o u 1 ® 13 1 0 CITATIONS ISSUED ❑PENDINGSLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME •
AM• 0 Utility
t 2 0 51 1 ARREST NAME 02 r 27 12025 04 28 ®PM 0 Unknown work zone type U1 15
x T
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 15
1530 Soto.Oscar 502 , , ❑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•---, , 1 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----; _, r INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L J i. e. r ,. (example:shuttle or charter bus):or X
Z 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
L <.__-A-.-.J n'`� } } } . transport) em loyee In thecoursee of their em yent example:employee
rsJ p
Not To Scale I � v transporter-usually a van type vehicle or passenger car):or CO
L L.___a.. va 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including y
0 - } } } for direct compensation(example::large van used for speific purpoe):o
_ I I I I I 111
'`� _ � L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires rive m
r
m a placardig(example:placards will be isplayed on the vehicle). ;p
Unit 1 -
CARRIER NAME Z
ADDRESS 0
an i. i. i... .4_Unit 2 o
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
0
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No Z
Form Number 0
m
M
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 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
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE