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HomeMy WebLinkAbout2025-00015839 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 lI 011100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003756316 u1 1 U2 1 1 1 U1 1 U2 U1 1 U2 U1 1 U2 4 4 U1 1 U2 *P 9* 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 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00015839 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED PRIVATE ❑Y ®N 03 11 2025 DAM ❑YES ®NO U1 -< S RANDALL RD Elgin mo /day/yr 07:59 ®PM FLOW CONDITION M _ ONC7!MI N E O W SOUTH St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ 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 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 5 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 NIC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 rn F 2 4 SYTM❑Y INS SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 t6•TDP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il a 4 COIN VEH 0 Ea 1 0 F. ELGIN I N I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *If Ves.See Sidebar Ut Z BU88153 IL 2024 Isui TELEPHONE IL D 0 2HG FA1F55AH582661 TRAVELERS ❑Y ®N U2 Rr'I in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Campos. Marcos 6166936692031 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 yr 12 _ X1 Ti 13-UNDER CARRIAGE 1O.i :., 2 FIRE ❑ ❑ U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 0 - POINT OF 8-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:=5 C•IO e1sVEH See •Sidebar❑ ❑ C CO I� pEAR` C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < RESP❑YONDER❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 1 3 08 / F 2 4 0 1 0 I71 / / #OCCS > / / UI 2 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 15 1 DNR DEER 31 / 11 /025 07 59 ®PM in a work zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 50 T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 ;, t 2 ❑ 1 NATURAL RESOURCES WA5'pringfieldL 62702 21 18 ! / 0 AM ❑Construction * ZJ 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING Utility SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 y t 2 El ARREST NAME 31 !11 /025 07 59 ®PM El, T Unknown work zone type U1 El AM 45 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ - ❑AM Workers present? ❑ 1554-Wagener.Vincent 702 ! / ❑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 Ji I I L ® 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` --I -' Nbi 7hShea r____ _ INDICATE NORTH combination):or A ———— BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C d - (example:shuttle or charter bus):or 0 L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 } } } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L i t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmt -1 _ CARRIER NAME Z ADDRESS O CO C) CITY/STATE/ZIP g i - t 4. MOTOR CARR.ID 0 Interstate ❑ Intrastate 5 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 �I. --- --1 - USDOT NO. ILCC NO. C m 73 Source of above Z . GVWR/GCWR m 0 <10,000 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. 71 73 Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown D Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0 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 cn LOCAL USE ONLY TRAILER VIN 2 m O TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 z ri TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z 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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE