HomeMy WebLinkAbout2025-00036584 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003653959
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00036584 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 E1
® ❑ RELATED ❑Y ®N 06 08 2025 ❑AM ❑YES ®NO U1 -<
S RANDALL RD Elgin 04:24
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
10 !MI N E S W HO S St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® ® pp Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 6 n
FOR DAMAGEDAREA(S) MO N( TOWED U1 O
NAME(LAST,FIRST,M) Burkhart.Samantha. L. m0 9 /
13-UNDER CARRIAGE 16) , 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 6 rn
F 2 4 SYTM❑Y ®S NE El UNK VEH. 0 AT CRASH 0 99-U 15- NKNOWN THER9 76•TOP 3 *Distraction Value 2 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL 6 I,.4 COM VEH 0 El 1 0
F. FIRST CONTACT 12 7 ;-1 _5 *Irves.See Sidebar U1
Z Oregon IL 61061 0 1 0 EP64123 IL 2025 REAR
TELEPHONE
IL D 0 5NMSH13E47H093887 Progressive ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 986534606 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ® N 2 eu
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMy 0 NOV ❑DV
/1 9 8 2 Yr Nissan Altima 2017 00-NONE ,�_"i 12'-_, DUE TO CRASH p (� 2
0 13-UNDER CARRIAGE 10 l E FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI 6 I,,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y_{__O ._5 •IfYes,See Sidebar H ELGIN IL 60123 0 1 0 DR54993 IL 2025 REAR 0
M
IL D 0 1 N4AL3AP6HC171666 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same 0364979-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER Y ® U1ID =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(!TELEPHONE) (EMS) (HOSPITAL)
2 3 09 / M 2 3 0 1 0
m
/ / #OCCS D
/ / U1 1 D
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 1 06/08 /2025 04 24 ®pm 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
O 2 0 28 44 / / ❑PM Construction
Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME Burkhart.Samantha. L. 12-610.2-B 752911 / / El PM SLMT
o u 1 ® 11 1 CITATIONS ISSUED 0 PENDINGTIME • ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE 0 AM 45
r 2 El ARREST NAME Burkhart.Samantha. L. 11-601-Ax 752909 / / pM Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑y 45
1538-Estrada. Leticia 800 386-Lynch 07 / 11 /2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }---_r__--; I I Itil combination):or
INDICATE NORTH —11
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' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} 1 - r r (example:shuttle or charter bus):or
d� Q�, Not To scale f
I 1 I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
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} } } transporting employee in the course of their employment(example:employee I °
transporter-usually a van type vehicle or passenger car):or w
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:- --}----; - } 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
�► I • } } (I)for direct compensation(example:large van used for specific purpose):or O
L I. t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
_r r -1- 1 1 1 r Hoppo7Rd I* I- l- I-- ADDRESS D
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1 I I , ,
CITY/STATE/ZIP g
- i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------4. - 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
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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
Black Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 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