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HomeMy WebLinkAbout2025-00016914 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 101101100 Hill I ID 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0037622 1 u, 1 u21 3 4 3 u, 5 U2 1 u, 1 u2 1 u, 1 U2 1 1 10 u, 3 U2 1 *P 0119 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 ❑$501-$1.500 ®ON SCENE 4 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00016914 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m 1 N RANDALL RD El09:59 ® ❑ RELATED ❑Y ®N 03 16 2025 ®AM ❑YES IX]NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING to y #OF MOTOR 0 SLOW 15 u) ❑ FT/MI NESW 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 Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES ❑NIAV ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 FROf�tr TOWED U1 O Miller.Anijah. N. Chevrolet Traverse 2021 00-NONE , " 12 OUE TO CRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE ©) ! FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ❑ 0U2 3 <<T1 F 2 4 SY❑Y ❑STM NEDUNK VEH. 0 ATCRASHD 99-UUNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it S �i 4 COM VEH 0 Ea 1 n F- FIRST CONTACT 1 7__1�_-_;__5 *If Yes.See Sidebar U1 0 Z Hanover Park IL 60133 0 1 0 EQ IL 2024 REAR TELEPHONE IL D 0 1GNERFKWOMJ191281 Permanent General Assuran ❑Y J N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Schroeder. Lorean. L. 1 B-I L 8111264 3 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 '1 9 yr 0 Jeep(after 19681�rokee 2021 00-NONE ,i_"�,1 12 _, DUE TO CRASH ❑ (� 2 0 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN O 0istracton Value 9 0 POINT OF S it �' 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR —J 5 FIRST CONTACT 3 7_ -5 *IfYes,See Sidebar BARTLETT IL 60103 0 1 0 EM26922 IL 2024 I 0 IL D 7 1 C4RJFAG5MC536305 State Farm ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 2310165-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 4 01 / :A / / UI 1 D / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z N 1 ® 11 5 03,16 l2025 09 59 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 ❑ 20 10 I ! ❑PM ❑Construction >F Z3 ❑ 1!>I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 o ® 11 5 ARREST NAME Miller.Anijah. N. 11-708 1538000194 / / El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 10 r 2 ARREST NAME AM 7 , , ❑❑pM ❑Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1538-Estrada. Leticia 800 368-Davenport , / ❑❑PM Workers present? ®N U2 10 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 -< ` ` -'- ' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C V - } (example:shuttle or charter bus):or Nor so .rr 1 T, L L.___A_._-i y _ I. } } 3. Is transporting empined to oyees 5 or fewer Inhecourseeo their rs employ nt example:employee a contract ner I ° transporter-usually a van type vehicle or passenger car):or 1 °" / 4. Is used or designated to transport between 9 and 15} } } g Po passengers,including the driver, C for direct compensation(example:large van used for specific purpose):or O L s s _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires rn \ r placarding(example:placards will be displayed on the vehicle). XI S Aa• \ _ __ > / \ ~ \ CARRIER NAME Z '�/ ' 4. \\\ S \ ADDRESS CITY/STATE/ZIP C)0 MOTOR CARR.ID 0 Interstate ❑ 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 . 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'; 0 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 White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE