HomeMy WebLinkAbout2025-00040157 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 011111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY *X003665920*
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00040157 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S RANDALL RD El In02:39
® ❑ RELATED ®Y 0 N 06 23 2025 ❑AM ❑YES ®NO U1 -<
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g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W RT20 EB RAMP COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 7 Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 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 4 0
1 1 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 9 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 9 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & iL 6 1,.4 COM VEH 0 0 1 0
~ ELGIN N I L 60124 0 1 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1
Z 1119105 IL 2025 REAR
TELEPHONE
IL D 4S3GTAM63H3727069 Safeco Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Z4171990 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 73
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NCv 0 DV
!1 9 9 6 International 14!ei Corpy yr . 2007 00-NONE 11"j t2---
DUE TO CRASH ❑ ® 20 73
o 13-UNDER CARRIAGE 10'i :., 2 FIRE 0 ® U2 C
M 2 4 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i�.�., 4 COM VEH ® 0 U1 CO
FIRST CONTACT 8 7 , _5 •IfVes.See Sidebar C
Bolingbrook IL 60440 0 1 P806165 IL 2025 REAR 0 Si)
IL D 7 2HSCNAPR17C532781 Great West Casualty ❑Y J N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
MDI Transportation MCP95191C BAC E
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)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 06,23 /2025 02 39 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0
1
2 ❑ 25 28 ) ! ❑PM ❑Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Hemesath. Patricia 11-306 273004348 ! ! El PM SLMT
S' N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
45
ARREST NAMEAM
7r 2 ❑ 1 / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El AM Workers present? ❑Y 45
273-Tucker.Craig 801 - r ! ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-•---, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }-- -i-- --; } } } r -, , ; ; , 1, ( combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 ........ J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 03
I- <.__-a-_-_-I , l• I- I- <--_-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 0
L L___-a____. 1 L L �____. . . 7 I. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
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-D 7
CARRIER NAME M DI Transportation Z
ADDRESS 10430 WOODWARD AVE 0
, CITY/STATE/ZIP Woodridge/ I L/60517 g
MOTOR CARR.ID El Interstate 0 Intrastate
❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
Y- --; Y- ; ; ; 536741 267855 USDOT NO. ILCC NO. m
xi
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown 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. WIDELOAEP 0 Yes ®No 2
TRAILER VIN 1 4M9DS2323L1017311 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ® ❑ 0 Z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/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 ® VEHICLE CONFIG. CARGO BODY TYPE 5 LOAD TYPE 3