HomeMy WebLinkAbout2025-00021416 ILLINOIS TRAFFIC CRASH REPORT sheet 1 a Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003798959
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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 ❑$501-$1.500 ❑ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00021416 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 T1
BOWES RD El In09:30
® ❑ RELATED ®Y 0 N 04 04 2025 ❑AM ❑YES El NO U1 —<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W S RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 2 !
yr 11.. 12 .O E
13-UNDER CARRIAGE 2 FIRE ❑ IE
101 O <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP
�3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $• iI 6 it COM VEH 0 Ea 1 0
I. FIRST CONTACT 3 7 :�-_;_OS •II Yes.See&debar U1 0
.... Streamwood IL 60107 0 1 EV80602 IL " ' E
TELEPHONE
IL D 5TDXK3DC3FS660621 Unique Insurance Company ❑v ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
99 Same ILP2807154 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Refused ❑Y ❑ N 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑Dv
!2 0 0 2 FR
Jeep(after 1968,�rokee 2010' 00-NONE O1' t2 "_1 DUE TO CRASH ❑ 2 73
0 13-UNDER CARRIAGE 10 I 2 FIRE ID El U2 C
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M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1:, COM VEH ❑ ® U1 W
FIRST CONTACT 11 7� 6 •(ryes.See Sidebar
F= HAMPSHIRE IL 60140 0 1 DD39074 IL I:EaR C
0 Si)
Z
IL D 1 J4PR4G K5AC152451 Country Financial ❑y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 Leon. Raul P010118844 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)I(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 04,05 /2025 01 22 ®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 0
2 0 20 15
N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
—a, ARREST NAME / / ❑PM
o N ® 11 1 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
f 2 ❑ ARREST NAMEAM
7 / / ❑❑PM 0 Unknown work zone type 45
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
561-Rendon.Joshua r ! El 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 03
< <.__-a-_-_, , 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 0
L L___-a____.: L L L ...._-..:_____� 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
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE