HomeMy WebLinkAbout2025-00029180 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03614082
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INVESTIGATING AGENCY DAMAGE TO ANY ❑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 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00029180 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m® ❑ RELATED PRIVATE ❑Y ®N 05 08 2025 ®AM ❑YES ®NO U1 -<
S RANDALL RD Elgin mo /day/yr 08:12 ❑PM FLOW CONDITION m
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01 D�i!MI N E O W HOPPS Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR NISLOW 3 Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS O
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 2 /
Dodge Ram ProMaster 2020 00-NONE „,_ Oi_, ODE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 i ' 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :il a 4 COM VEH 0 j$J 1 0
" �- CRYSTAL LAKE I L 60014 0 1 0 FIRST CONTACT 12 r ; __5 *If Yes.See Sidebar U1
Z3017545B IL 2024 E
TELEPHONE
IL D 0 3C6TRVAG2LE141621 VALLEY INSURANCE GROUP ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 ENTERPRISE FM TRUST A998644 03 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
14 0
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g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 IIIAV 0 NOV 0 Dv
9 yf 7 Chrysler Pacifica 2021 00-NONE ,;_I t2..-_, DUE TO CRASH ❑ 0 2 x
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistraellon Value 0
POINT OF s i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II 5 l'r_
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar
Z ST CHARLES IL 60175-5480 0 1 0 MTRSH I P IL 2025aR
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D
IL D 0 2C4RC3PG3MR538027 STATE FARM ®V ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
South Elgin Fire 99 9 Same 2246878-SFP-13 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Other RESPONDER U1 =
(UNIT) (SEAT) (DOS) (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
Ei N 1 ® 11 1 05,08 /2025 08 13 0 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 C)
v 2 0 28 99 05,08 /2025 08 13 ❑PM ❑Construction *
R 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ®AM ❑Maintenance U2
-a, ARREST NAME PAINTER. IAN.C. 11-601 1551000080 05/08/2025 08 18 ❑PM SLMT
1 ® 11 1 0 CITATIONS ISSUED PENDING
o NSECTION CITATION NO. ROAD CLEARANCE TIME
0 Utility
AM 45
r 2 El ARREST NAME 05/08 /2025 08 45 MPM ElUnknown work zone type U,
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1551-Dede.Joseph 702 06 , 10,2025 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
1 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
c ` -'- ' r INDICATE NORTH combination)or .Z-1
Not To Scale
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ (example:shuttle or charter bus):or C
Q r , r 3. Is desgned tol car 15 or fewer passengers and operated a contract carrier O
y I. I- . transport) em to ees In thecoursee of their em
ng p y pbyment(example:employee
L -----}----; - } } 1 4a Is uosed or drter- es gnated to transport betweelly a van type vehicle or n 9 ad 15enger rpassengers,including the driver. co® it
1 1 for direct compensation(example:large van used for specific purpose):or O
L L----a. r i$• i l. i. . I i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—I
CARRIER NAME Z
ADDRESS 0
w
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
Source of above Z
. If Yes,Name on placard 0
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
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'LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White 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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE