HomeMy WebLinkAbout2025-00028419 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100001111010 100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00028419 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
1020 S RANDALL RD El 12:38
® ❑ RELATED 0 Y ®N 05 05 2025 DAM El YES ®NO U1 -<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W 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 ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
1 2 !
yr
Hyundai Sonata 2006 00-NONE 1 DUE TO CRASH Ely ++ 12 - EN E
13-UNDER CARRIAGE +�i 2 O FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 0 M
F 2 4 SYTM❑Y ®NNE DUNK VEH. 0 AT CRASH 0 99-UNK 15- NOWN THER9 +6•TOP® *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL 6 I,.4 COM VEH 0 0 1 0
~ Streamwood I L 60107 0 1 0 FIRST CONTACT 2 7_: _-5 *!rues.See sidebar Ui
Z EW57649 IL 2025 ' E
TELEPHONE
IL D 0 5NPEU46F76H036700 American Alliance ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Castillo Calderon.Oscar. R. I LAA-1042480-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑N,Iv 0 NKV ❑DV
!1 9 9 2 Nissan Maxima 2010 00-NONE 0.. QNT!--O DUE TO CRASH ❑ (� 2 x
o _ 13-UNDER CARRIAGE 10( ) 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1r.
6-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 0
POINT OF 6 i1�I-4 COM VEH ❑ ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B _.5 •(ryes,See Sidebar
ZALGONQUIN IL 60102 0 1 0 Z201169 IL 2025 iiEaR 0 C
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IL 0 1 N4AA5AP1AC870873 Shelter Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 1 2-1-1 09731 26-2 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
1 3 06 /
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/ / 2 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 05 105 l2025 12 38 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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v + 2 ❑ 2 28 1 1 0 PM ❑Construction
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, u ARREST NAME / / ID PM '
1 El 11 1 0 CITATIONS ISSUED ❑PENDING • UtilitySLMT
S' SECTION CITATION NO. ROAD CLEARANCE TIME 0
t 2 El ARREST NAME 05 r 05 /2025 12 38 ®PM ❑Unknown work zone type U1 El AM
15
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID1542-Chase. Ethan 801 - r ! ❑❑PM Workers present? ®N U2 15
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
r____—t 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 truck trailer -<
` ` --I -' = • INDICATE NORTH combination):or —I
fl BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - _ } (example:shuttle or charter bus):or C)
,y N«m same , 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
51 } r } transporter-us employees vantypcourse of vehicleorpirempbymant(example:employee
Po y type passenger car):or c0
L -----}----l. 1 t ` - } } } C
•4. Is used or designated to transport between 9 and 1 passengers,including the dryer,
4 for direct compensation(example:large van used fors cific purpose):or
---. , - ,: - L L 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
^ placarding(example:placards will be displayed on the vehicle). ,Zmt
CARRIER NAME• Z
1 I ! I ADDRESS
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C)
CITY/STATE/ZIP 2 I I I I
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MOTOR CARR.ID 0 Interstate 0 Intrastate
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° Not in Comm./Govt. 0 Not in Comm./Other
—Untti r ,
• 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 E
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE