HomeMy WebLinkAbout2025-00022278 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 1111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003785361
u, 1 U21 3 4 1 U1 3 U2 1 U, 1 U2 1 U, 1 U2 1 1 2 U, 3 U2 4 *P 0 1 1 9*
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 ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00022278 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 �I
® ❑ RELATED ®Y ❑N 04 09 2025 ®AM ❑YES ®NO U1 -<
S RANDALL RD Elgin08:12
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W SOUTH ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 21 PEON. ❑EWES ❑NW ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) T TOWED U1 Q
Y N 4 0
FOR DAMAGEDAREA(S) FROM
Elders.Andrew.C. 0 6 /
yr 13-UNDER CARRIAGE I ! FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 4 M
M 5 3 SYSTEM IN ENGAGED 15-OTHER 9 76-TOP�3 =
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF l 6 � COM VEH 0 ❑ 1 n
F. FIRST CONTACT 3 7 _,-_;_(9 •IIYes.See&debar U1 0
Z ELGIN IL 60124 A 1 REAR
TELEPHONE
IL ❑Y ❑N U2 1--
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 1-1
Elgin Fire 1 3 1 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
Provena St.Joseph ❑Y ® N 2 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEON. 0 EWES ❑row 0 NCv 0 DV
/1 9 9 4 Honda Accord 2018 00-NONE 11_' 12 "_, DUE TO CRASH ❑ ! l 2
0 13-UNDER CARRIAGE 9 I 2 FIRE ❑ El U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 .i�..__4 COM VEH D ® U1 CO
FIRST CONTACT 11 7 _5 •If Yes.See Sidebar C
ELGIN I L 60123 0 1 0 DC92610 I 0 fp
IL 1 HGCV1 F1XJA251531 Amarican Family Insurance ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Mendez. Ivan 41066-7465-79 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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 ❑Y U2 Z
N 1 ® 11 4 Elders.Andrew.C. 700W U Haul bike 04,09 ,2025 08 12 ®❑PM AM 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
v 2 3066 BRIDGEHAM ST ELGIN IL 60124 25 99 04,09 ,2025 08 14 ❑PM 0 Construction >F
R O ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
3 ®AM ❑Maintenance U2
-a, ARREST NAME Elders.Andrew.C. 11-305-A W1552000037 04,09 l2025 08 18 ❑pM SLMT
oN ® 13 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
t 2 0 ARREST NAME El AM
T ❑PM 0Unknown work zone type U1
, r
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1552-Thompson.Ahmad Rashad 702 397-Jones , / ❑❑PM Workers present? ®N U2 45
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 truckrtrailer -<
i- }---.r----; II I. combination):or
INDICATE NORTH p1
L I i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or C
I ' I.-I
A II I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} transporting employees in the course of their employment(example:employee X
®b""!® } transporter-usually a van type vehicle or passenger car):or CO
r w 1
i. L.__-a__-_. - -l�� 4. Is used ordesi natedtotrans transport passengers,including y} } } g po passen rs,includi the driver,
I for direct compensation(example:large van used for specific purpose):or
L L--_-a-___. J : 5. Is anyvehicle used to transporthazardousmaterial(HAZMAT)thatre requires���i�1� W any Q m
placarding(example:placards will be displayed on the vehicle).
D
CARRIER NAME Z
rZ
7.ff,
ADDRESS O
CITY/STATE/ZIP 0
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I. --- --• - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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 :
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
u 1 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 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE