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HomeMy WebLinkAbout2025-00033792 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100000 III I 11111H DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003633E-S9* u, 1 U21 3 4 1 U1 3 U2 U, 1 1_12 1 U, 1 U2 1 1 10 u1 5 U225 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 202512025-00033792 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m ® ❑ RELATED ' V 0 N 05 27 2025 ❑AM ❑YES ®NO U1 -< N RANDALL RD Elgin02:19 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W HOLM ES RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 8 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 53 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROM TOWED U1 Hulslander. Kaitlyn. M. 0 4 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m F 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�s 4 COM VEH 0 0 1 0 F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1 Z Woodstock IL 60098 0 1 V386375 IL 2026 REAR TELEPHONE IL D 0 STDZSKFC8PS105651 State Farm ❑Y Igl N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 1340987SFP13 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI 0 DRIVER 0 PARKED 51 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr _ 13-UNDER CARRIAGE I ;-2 FIRE 0 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 0 X a NJ Y N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value POINT OF 8 '4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -'-it COM VEH ❑ ® CO FIRST CONTACT 11 7 _, _5 ••(ryes.See Sidebar H P1203567 IL 2025 I 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 3AKBCYCY2G DGT6920 unknown ❑Y 0 N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Monroe Transportatio unknown SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = {UNIT) tSEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 05,27 l2025 02 19 ®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 o" 2 ❑ 07 99 1 1 ❑PM ❑Construction >E R 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 ou ® 11 4 ARREST NAME Hulslander. Kaitlyn. M. 11-306 W482000530 ! ! ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑El AM Utility t 2 ❑ ARREST NAME 05l 27 l2025 02 19 ®PM ❑Unknown work zone type U1 5O x T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 50 482-Flentcy e.Jeremy 502 - 1 ! ❑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. F ----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 -' I I I I I. INDICATE NORTH combination):or -I I I I I N7RMqall7nd i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n r - r r ,. (example:shuttle or charter bus):or C) I I I , , , , I t v v y ! 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I I I A ` - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L Unit r } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N — I olrnntrid for direct compensation(example:large van used for specific purpose):or O 4 L �____a____� 1 _ � i i t 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires m 1 placarding(example:placards will be displayed on the vehicle). ;p t = -- '1 V - - CARRIER NAME Z l O ADDRESS! II II ' ~ I I t D Not To Scale j CITY/STATE/ZIP I I - MOTOR CARR.ID ElInterstate ElIntrastate I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 --- --1 - USDOT NO. ILCC NO. m m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes ®No 2 TRAILER VIN 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 Silver Red u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE