HomeMy WebLinkAbout2025-00033080 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 6 Sheets Mill pH H 11111 011011000 Hill I111100111100
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003832&57-
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-51.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500 0 NOT ON SCENE(DESK REPORT)
0 AMENDED ® B Injury and/or Tow Due To Crash YR 202512025-00033080 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
300 S RANDALL RD Elgin11:53
® ❑ RELATED ❑Y ®N 05 24 2025 ®AM El YES El NO U1 -<
_ PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ FT/MI NESW 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 O DRIVERLESS 0 PED CI PEDAL 0 EOUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Enri uez Garcia.Ana. M. 0 1 / /1 9 y9 2 Dodge Journey 2006 00-NONE ,, , DUE TOCRASH ® ❑
NAME(LAST,FIRST,M) q mo r Q
13-UNDER CARRIAGE FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0U2 0 171
F 2 SYTM IN ENGAGETHER
4 ❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 9 1I6•TOP(3 ,Distraction Value ALGN =
F F
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST NTOONTACT 99 7_)[® o CI OM VEH Sidebar El U1 1 0
Z Chicago IL 60634 0 1 0 EZ73761 IL 2025 T'
TELEPHONE
IL D 3C4PDDEGXGT140876 None ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 2 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuv 0 NOV 0 Dv
yr Honda Odyssey 2015 00-NONE 0 Qj.O DUETO CRASH ❑ ® 1 X/
.. _ 13-UNDER CARRIAGE 10 I I.. 2 FIRE ID El U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 X
a El Y N D UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ) II' 4Ut
to
FIRST CONTACT 99 7 6 `�.6 COM•IesvSeeSidebar❑ ® C
F-- AS35470 IL 2025 REAR 9 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
SFNRL5H67FB045886 Ameica Select Insurance C ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Murray.Tracy.A. WNP180213R BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 Target Red Concrete Sphere 05,24 /2025 11 53 ®❑PM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
E 2 0 43 5 300 S RANDALL RD Elgin IL 60123 19 28 / / PM
0 ❑Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
-a, ARREST NAME / / 0 PM '
o N 1 ® -
11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
T 2 ❑ 10
AM
T ❑PM 0 Unknown work zone type U1
ARREST NAME / / 0
ncf- OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 10
1545 VanEycke. Brier sot / / ❑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. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` '' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
0 - (example:shuttle or charter bus):or
I- L.___A.._.1 Noi To Se81e 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
j - } } } transporting employees In the course of their employment(example:employee 73
---- transporter-usually a van type vehicle or passenger car):or w
L L.___a.. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
' �M! •�s•.'������ t i. i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
h i ! 'D
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
'
"�' r "' _ ADDRESS O
Mil, n
-'__- _ CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i. --- '-4 - USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD"; ❑Yes 0 No =
TRAILER VIN 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
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
_Redmons/Impound Lot Garage . 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