HomeMy WebLinkAbout2025-00020457 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037762134
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00020457 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 04 01 2025 ®AM ❑YES ®NO U1 —<
N RANDALL RD Elgin 08:56
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION M
FT l MI N E S W WESTFIELD DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ICU 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 /
yr 13-UNDER CARRIAGE 10 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 I'..
F 2 SY n 15-OTHER
4 ❑Y ®SNE M DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it S 4 COM VEH 0 Ea 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 00 7 ;1 _-5 *IIYes.See Sidecar U1
Z ALLMIGHT IL 2025 Ismi
7 TELEPHONE
IL D 0 4T1 BE46K88U200134 Progressive ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Calderon.Jamie 963339226 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 A•
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 uv 0 KV ❑Dv CIRCLE NUMBER(S) U1
/1 9 6 4 Honda Passport 2024 00-NONE 'o,� t2 (,�2 DUE O CRASH 0 ® U2 2 C
o yr 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9:1,6•TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF t COM VEH ❑ ® Ut CO
*Distraction Value 0
S 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 Q _,L_ If Yes.See Sidebar-5 •
Huntley IL 60142 0 1 0 GIRLSX2 IL 2025 REAR0 N
IL D 0 5FNYF8H61RB018594 progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Harrison. Brian 962676397 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U2 m
##OCCS y
/ / 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
co
u 1 CD 11 1 04/01 /2025 09 02 0 PM in a Work Zone? ®N DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1
O T 3 n
2 ❑ 2 99 + / ❑PM• ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Calderon. Maria. I. 11.32.040 1531000020 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 ❑ ARREST NAME AM
T / / PM 0 Unknown work zone type 45
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
1531-SchEmbach.Jack 901 275-Engelke 05 , 13/2025 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; �7y+ I - I combination): more thanpounds(example:truckortruck/trailer('IriI )
1. Has a rating10,000 -<INDICATE NORTH
BY ARROW or
2 Is used or designed to transport more than 15 passengers including the driver n
11 - (example:shuttle or charter bus):or X
units
- - I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
Not To Scale I n 1 - I. } } transporting employee in the course of their employment(example:employee X
L _ transporter-usually a van type vehicle or passenger car):or w
L -----}----; i i - } } 1- 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
• for direct compensation(example:large van used for specific purpose):or O
L L____a____. Waetrierd?D^"B ilk _ l. I 1 ,_ 5. Is any vehicle used to transport anyhazardous material
(example:placards will be isplayed on the vehicle). XI
}�I 2#
�. CARRIER NAME Z
r r f -: .__It \, �, __ ADDRESS D
\ n
CITY/STATE/ZIP g
N7RMid -
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 USDOT NO. ILCC NO. m
XI
Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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
Blue Gray
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE