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HomeMy WebLinkAbout2025-00019973 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 0 00 0010 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003771371 u, 1 U21 3 4 2 U1 3 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 11 u1 1 U211 *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 El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00019973 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �l ® ❑ RELATED ®Y 0 N 03 30 2025 ®AM ❑YES ®NO U1 -< S RANDALL RD Elgin 08:09 _ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m FT l MI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n f tf TOWED U1 FOR DAMAGEDAREA(S) FROM 0Carba al. Brandon 0 1 / yr 13-UNDER CARRIAGE ©, :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 rn M 2 SYTM IN ENGAGEis-OTHER 4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 5 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�S 4 COM VEH 0 j$J 1 0 ~ ELGIN N I L 60120 B 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1 Z40080716 IL 2026 REAR TELEPHONE IL A 7 1 GCG K13U 12F107247 State Farm ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same 3441053-SFP-13 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lilyi 0 v 0 DV !1 9 yf 0 Mitsubishi Lancer 2010' 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C .. mo 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & 1 S --4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,�=Q)OS C. (ryes.See Sidebar C ELGIN IL 60123 B 1 0 AN41317 IL 2025 AR Si)0 IL D JA32X8HW8AU004043 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 0611089-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused 0 Y°ND 0 N u1 = KNIT) (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 ❑Y U2 Z N 1 ® 11 4 31 /01 lO25 08 09 ®❑pM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) OT 2 ❑ 28 25 31 /01 /025 08 11 ❑PM ❑Construction E R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 z J ®AM ❑Maintenance U2 a1 ® 11 4 ARREST NAME Carbajal. Brandon 11-601 1552000025 31 /01 /025 08 15 ❑PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility AM U1 45 t 2 ❑ ARREST NAME 31 /01 /025 08 40 [�PM ❑Unknown work zone type 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Am Workers present? ❑Y 45 1552-Thompson.Ahmad Rashad 702 310-Zierk 41 / 51 /025 01 30 0 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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C / } (example:shuttle or charter bus):or} r rr X A 3. Is designed to carry 15 or fewer passen ers and o rated a contract career O ,o14/4 } } } transporting employees In the course of their employment(example:employee X — e transporter-usually a van Type vehicle or passenger car):or w -- } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose):or O L L-. ..i.. --. b d - I. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m �Y placarding(example:placards will be displayed on the vehicle). XI i l ® - , ,Vr - CARRIER NAME Z /1J `y > O ADDRESS U) i CITY/STATE/ZIP - i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 0 Yes J No ❑ Unknown A 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 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 Tan Red u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE