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HomeMy WebLinkAbout2025-00026786 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 0III 111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003600383 u, 1 U21 1 1 1 U1 5 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 4 u2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00026786 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n N RANDALL RD Elgin03:46 ® ❑ RELATED ❑Y ®N 04 28 2025 ❑AM ❑YES IX]NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W FOX LN COUNTY PROPERTY ❑Y 1�1 N DOORING Ely #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 FOR DAMAGEDAREA(S) FROhrr TOWED U1 0NAME(LAST,FIRST,M) o !1 9 9 5 Ford Fusion 2016 00-NONE , 12 , DUE TO CRASH ❑ VI E 13-UNDER CARRIAGE ©,I !�. 2 FIRE ❑ IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 M F 2 SYTM IN ENGAGE4 ❑Y ®SNE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�a �i 4 COM VEH 0 j$J 1 0 ELGIN N I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *II Yes.See Sidebar U1 Z EK11103 IL 2025 . E TELEPHONE IL D 0 3FA6P0H79GR365171 American Alliance ❑Y IlN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same I LAA-1014770-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused 0 Y ® N 2 0 �{ DRIVER ❑ PARKED 0 DRIVERLESS 0 RED 0 PEDAL 0 EWES 0 uv 0 NCv 0 DV CIRCLE NUMBER(S) U1 !1 9 8 5 Toyota Prius 2013 00-NONE ,1_"j 12..-_, DUETO CRASH ❑ Ig 2 x o 13-UNDER CARRIAGE 10;1 2 FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3 * X ❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN O 0istrac) n Value 9 0 POINT OF 8 i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 Lo-_ FIRST CONTACT 4 7 ,__5 •(ryes,See Sidebar C Z Chicago IL 60631 0 1 0 S314129 IL 2024 REAR 0 Si) Z IL D 0 JTDKDTB35D1039334 GM National Insurance Com ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 135002638707566 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(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 u 1 ® 11 1 04/28 l2025 03 46 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) o" 2 ❑ 06 99 ) / 0 PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Cruz Lopez. Dinora.S. 11-801-A 1547000047 / ! El PM SLAT o N I]CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 0 AM r 2 0 ARREST NAME 04l 28 l2025 03 47 ®PM El Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1547-Steele.Justin 901 391-Jacobucci 06 ,03,2025 09 00 ❑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 Not To Scale i 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- }____r____1 A _ INDICATE NORTH nation):of I I 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X I ; I 4, d 0 .3 so me Unit'2 I r r r I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O -.I-. I I. } } transporting employees in the course of their employment(example:employee73 transporter-usually a van type vehicle or passenger car):or co -----}----; } }I I - 1 } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. w for direct compensation(example:large van used fors specific purose):or O L____a..... I. i. i 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires m a 4* y placarding(example:placards will be displayed on the vehicle). XI e 1 e __ — CARRIER NAME b Z n ADDRESS I I / I I V) CITY/STATE/ZIP g I I I I 5 I I I - MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other r ;____Y____1 - 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 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 No 0 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 VIM 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 Red White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE