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HomeMy WebLinkAbout2025-00036465 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 8 Sheets 01111101111 I0110110000100 II fll III II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO038:458.93 u, 1 U21 3 4 2 U1 6 U2 1 U1 1 U2 1 U1 1 U2 1 5 15 U, 1 U2 1 *P 0119 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 ❑5501-51.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00036465 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 06 07 2025 DAM ❑YES ®NO U1 -< N RANDALL RD Elgin 11:59 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD DO U2 —I Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n 1 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q NAME(LAST,FIRST,M) Lawson.Jade. N. mo0 / /2 0 0 4 Ford Fusion 2020 00-NONE it_ O •I_1 DUE TO CRASH ® ❑ 13-UNDER CARRIAGE 10 i , 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 6 m F 2 SY is-OTHER 8 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 ,oistractionValue ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8,_iL a 4 COM VEH ❑ j$J 1 0 ~ ELGIN I L 60123 B 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1 ZCF79125 IL 2026 REAR TELEPHONE IL 0 3FA6POT90LR254009 State Farm ❑Y ISI N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Lawson. Brenda.A. 1785059-SFP-13 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y ® N 2 c p; DRIVER 0 PARKED 0 DRIVERLESS 0 PED ❑PEOAL 0 EWES 0 iiuv 0 i v 0 Dv 1 Yr 9 9 9 Ford Explorer 2023 00-NONE O, ©Li DUE TO CRASH rg ❑ 6 x o 13-UNDERCARRIAGE ta,i Ic. 2 FIRE ❑ ® U2 C c F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 .i ;i.-.4 COM VEH 0 ® U1 CO FIRST CONTACT 11 7 _, _5 •• •IfYes.See Sidebar C ELGIN IL 60120 B 1 0 M P23128 IL I Si)0 M IL D 0 1 FM5K8AC6PGB12449 Charter Oak Fire Insuranc ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 City of Elgin 8109160P901 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 11 1 61 /12 /25 11 59 ®AM 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 C) 2 0 08 20 61 /12 /25 00 00 ❑PM 0 Construction E R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 z J ®AM ❑Maintenance U2 a ® 11 1 ARREST NAME Lawson.Jade. N. 6-20-E 752904 61 /12 /25 00 05 ❑pM• • El Utility SLMT ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM N 50 r 2 El ARREST NAME Lawson.Jade. N. 3-416 752908 61 //2 /25 00 50 MPM 0 Unknown work zone type U1 2 2 3 El El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 50 489-Reynolds.Allison 900 331-Ziegler 71 / 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 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 _IR ® 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` --I -' r INDICATE NORTH combination)or p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van typecar vehicle or passenger ca):or C L -----}----; ey„ - • } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or o — t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI m -1 _ CARRIER NAME Z ADDRESS w C) CITY/STATE/ZIP g _ i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate ' � i. 0) I I , I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 � --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 0 Yes 0 No ❑ Unknown A 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 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 Silver Black 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE