HomeMy WebLinkAbout2025-00030225 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 0 ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00030225 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 "I
COLLEGE GREEN DR Elgin 07:18
® ❑ RELATED ®Y 0 N 05 12 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day!yr ®PM FLOW CONDITION Ill
FT!MI N E S W S RANDALL RD COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 23 C)
! ! FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Unknown,O. Unknown Unknown 00-NONE „ 12 , DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 1 IE
01 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 23 M
5 3 SYSTEM IN O ENGAGED 0 15-OTHER 9 16.TOP 3 _
❑Y ®N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
s 4 COM VEH 0 j$J
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1[6 !i,_ 1 0
~ 0 1 CO FIRST CONTACT 12 7_; _5 *u Yes.See Sidebar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 99 0
x DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
/1 9 6 9 Honda Accord 2013 00-NONE i1_"j 12'-_, DUE TO CRASH ❑ 2 73
0mo 13-UNDER CARRIAGE 16'I 2 FIRE 0 ElU2 C
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y lYi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 . 6 1"_ COM VEH ❑ ® ut CO
F,,, FIRST CONTACT 7 O7 _, _6 •)ryes.See Sidebar
ELGIN Z IL 60124 0 1 0 9496916 IL RFJ C
0 Si)
M
IL D 0 1 HGCT1 B86DA015634 Geico ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 6194282643 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER®N U1 =
(UNIT) (SEAT) (DOB1 (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
W 01 / M
m
/ / #OCCS D
71
/ / U1 1 D
/ / 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 4 05,12 l2025 10 59 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
57 2 0
03 28
N 3 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• 0 Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
-a, ARREST NAME / / ❑PM '
o u ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
50
r 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 447-Collins, Dominique 702 331-Ziegler , / ❑❑PnMn Workers present? ®N U2 50
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
0 ADDITIONAL UNITS FORMS.
r -- r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and:I Z
Not To Scale I 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
�____r----; 1 1 `+ v I combination):or —I
INDICATE NORTH p1
't : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
< <----�;-•-•j / ` 0
' r - trasdrtig emned tploo aeeslIn he couse of 5 or fewer passengers
er employment employee a contract ner CO
r ""s o C trasppoortenrg-usually a van type vehicle or passenger car):(example:r
L L-----}----+ - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the dryer, w
fo
on(example:
or specific
___.: r r / _ i L 5 r Is y vehicclle used to transport sport large hazardous material(HAZMAT)thatrequires 71
:or L L A ( M
�\ ® anyany m
1 r placarding(example:placards will be displayed on the vehicle). �
4% t t - '1
CARRIER NAME Z
ADDRESS 'n
C)
CITY/STATE/ZIP g
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
' ❑ Not in Comm./GaA. ❑ Not in Comm./Other 00
(4) i. i. i. .:. : USDOT NO. ILCC NO. C
Xl
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD? ❑Yes 0 No 2
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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: 9 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