HomeMy WebLinkAbout2025-00031133 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III 11 IIII
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A 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$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00031133 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
N RANDALL RD El In03:37
® ❑ RELATED ❑Y ®N 05 16 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
5 !MI N E S W Royal Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 Cl)
yKane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
1 FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) Rutkowski. Donna. M. mo
13-UNDERCARRIAGE 101 12!. 2 FIRE 0NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 4 ❑Y ® n is-OTHER
SYSTEM
❑UNK VEH. AT CRASH D 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F• POINT OF S_i L S i 4 COM VEH 0 j$J 1 0
FIRST CONTACT 1 7. •, - *IrYes.See Sidebar U1
Z Saint Charles IL 60174 0 1 0 MWD-WV IL 2025 REAR
TELEPHONE
IL D 0 1 C4RJ FBG7KC583699 Allstate ❑Y Igl N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 969730211 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 NOV 0 Dv
!1 9$5 Honda HR-V 2018 00-NONE 111 12 {,� D2 FIRE LIE OCRASH D ® U2 2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9:1,6•TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN •t •Oistractlon Value 9 g
POINT OF 8 � li, 4 COM VEH D ® Ui W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
FIRST CONTACT 7 Q _,�_-5 •If Yes.See Sidebar
Z Chicago IL 60631 B 1 0 PU R30 IL 2026 I 9 Sn
Z
IL D 0 3CZRU6H52JG709518 GM National ❑Y ®N RDEF XJ
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),(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 51 ,61 l025 03 37 ®AM 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)
2 ❑ 28 20 51 ,61 ,025 03 39 ®pm ❑Construction
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R ❑ igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Rutkowski. Donna. M. 11-601 1530000371 51 /61 l025 03 44 ®pM SLMT
S' N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 ElARREST NAME 51 +61 1025 03 58 ®PM 0 Unknown work zone type U1 50
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 50
1530-Soto.Oscar 502 61 , 12 ,25 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 unitshave 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
II 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }---_r----; combination):or
INDICATE NORTH p,
Not To Scale 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ - } (example:shuttle or charter bus):or 0
L A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee X
nB. transporter-usually a van type vehicle or passenger car):or w
L L.___a__. u� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C` ,` } } for direct compensation(example:large van used for speific purpoe):o
I I I r\ \ rive 0
L ..i.. .I. Q } } } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
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Icl — CARRIER NAME Z
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-- ADDRESS 'n
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
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N?Randall?Rd USDOT NO. ILCC NO. m
Source of above z
. 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
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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
0
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
Black Gray
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/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE