HomeMy WebLinkAbout2025-00017144 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER 31,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00017144 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
® ❑ RELATED PRIVATE
❑Y ®N 03 17 2025DAM ❑YES E)NO U1 -<
N RANDALL RD Elgin mo /day/yr 04:11 ®PM FLOW CONDITION m
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�r, COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 Cl)
Ixl- ®!MI N E O W FOX Ln WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 9 0
FRobrr TOWED U1 0
NAME(LAST,FIRST.M) Dublin. Michael mo Ford Escape 2021 00-NONE 11_ O I_, DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 i ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 9 (CTl
M 2 SY is-OTHER
4 ❑Y ON E DUNK VEH. O AT CRASH D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r POINT OF iII CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR s 6 i_i,4 COM VEH 0 j$J 1 00
F. FIRST CONTACT 6 7_;L-Q, _5 *IrYes.See Sidebar Ut
Z SOUTH ELGIN IL 60177 0 1 9387376 IL 2025
TELEPHONE
IL A 7 1 FMCU9H98M U B20860 State Farm ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 03886418-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEO ❑PEDAL 0 EWES ❑NMv 0 KCv ❑DV
� 1 9 9 8 Volkswagen Golf 2001 00-NONE 11_-1 t2..-_1 DUETO CRASH ❑ !g 2
o Yr 13-UNDER CARRIAGE 10;1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI 6 l',_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar
H ELGIN IL 60123 0 1 CR64271 IL 2026aR
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IL D 0 9BWGS61J714039378 Garrison Prop Casualty ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same USAA0144947797101 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 03,17 (2025 04 11 ®PM in a Work Zone? ®N DIRP co
r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: U1 5 C)
T 2 ❑ 11 1
❑AM
N 3 ❑ 0CITATIONS ISSUED 0PENDING 1 ( 1 - ❑PM• ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a ARREST NAME / / 0 PM '
,
1 ® 1 1 1 ❑CITATIONS ISSUED PENDINGSLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
0
Utility
r 2 ❑ ARREST NAME 03(17 (2025 05 32 ®PM ❑Unknown work zone type U1 0 AM
55
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? 0 Y 55
1507-Ruiz.Alondra 502 04 (08,2025 01 30 ❑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.
0 A CMV is defined as for vehxae used to tra and:
r ----,5-••--, ; any mo nsport passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} }-- -;-- --; } } } r -, , ; ; , 1, ( combination):or —I
INDICATE NORTH X1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' J. , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. 1 i. <--_... . J transporting edmployeeslin5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < .---_-a-___� , J. , , 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 L___-a____.I L L L ...._-..i._ 1 t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
i.
ADDRESS 0
th
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
73
Source of above z
) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m
Z
GVWR/GCWR 1
El <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. P3
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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
73
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Green
u 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE