HomeMy WebLinkAbout2025-00021501 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
I01101100
IVIII
IIIIIII 11000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00377707O
u, 1 U21 3 4 1 u, 8 U2 1 u, 1 u2 1 u, 1 U2 1 5 12 u1 1 u2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-51,500 0 ON SCENE 3
VEHICLE/PROPERTY ❑OVER 51,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
❑AMENDED YR 2025I 2025-00021501 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mRANDALL RD Elgin
® ❑ RELATED ®Y 0 N 04 05 202512,— ❑YES El NO U1 -<
PRIVATE mo /day/yr 10:01 ®PM FLOW CONDITION M_
�O C7!MI N E O W HOPPS Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
18: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 3 0
0 7 /
yr 13-UNDER CARRIAGE 101 12! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 4 SYTM❑Y ®SNE DUNK VEH. O AT CRASH 0 99-UNK 15- NOWN THER9 16•TOP 3 *Distraction Value ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 I,.4 COM VEH 0 E! 1 C)
~ ELGIN I L 60124 0 1 0 FIRST CONTACT 7 O7 _; __5 *If Yes.See Sidebar U1 0
Z3890242 IL 2025
TELEPHONE
IL D 1 C6SRFLT1 KN529347 Allstate ❑Y ®N U2 Ill . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 922896012 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 DV
2 0 0 7 Saturn ION 2004 00-NONE 1.,-j t2..-_, DUETO CRASH rg ❑ 2 x
o Yr 13-UNDER CARRIAGE 1 FIRE 0 ® U2
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9I1,6-TOPO3 * X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 �., 4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 6 7�� —_,A *!ryes,SeeSidebar
ELGIN IL 60123 0 1 0 ES64938 IL 2025 REAR
0 N
IL D 1G8AJ52FX4Z186349 GEICO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 6080156240 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / 2 3 0 1 0
m
/ / S#OCC D
71
/ / u1 2 D
/ / 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 4 04,05 ,2025 10 01 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 20 99 , , ❑PM ❑Construction
Z3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
-, ® 11 4 ARREST NAME Bucaro, Rocco.J. 11-708 1535000186 , r El PM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
r 2 El ARREST NAME 04!05 i2025 10 01 ®PM ❑Unknown work zone type AM U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1535-Solis, Laura 801 391-Jacobucci 04 ,22,2025 01 30 ElPM ®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
I 1. Has weight ratingmore thanpounds(example:truck or truckrtratler -<1. tin 10,000
} ' ' 1 / :ij I I I. INDICATE NORTH
0
r 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r
r (example:shuttle or charter bus):or 0
I- A - - 3. Is desgned to carry 15 or fewer passengers and operated by a contract career O
} } } transporting employees in the course of their employment(example:employee 73
Not To Soefe j transporter-usually a van type vehicle or passenger car):or CO
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 O
L i — — t i i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
` I I p CARRIER NAME
_ I
I ADDRESS D
to
I 1 CITY/STATE/ZIP 0
I I - i. i. i. i. 4. MOTOR CARR.ID 0 Interstate ❑ Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; - USDOT NO. ILCC NO. m
XI
Source of above 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. Xl
Xl
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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
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 Gray
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE
DUE