HomeMy WebLinkAbout2025-00041572 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110000 fl fl fl 1000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003670080'
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1,500 ❑ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00041572 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
1425 N RANDALL RD EIin09:30
® ❑ RELATED ❑Y ®N 06 29 2025 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
F 9 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN $ 4 `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 Ii COM VEH 0 g! 1 O
H 1- Unknown UnknowrUnknown 0 9 FIRST CONTACT 99 7_;mai_-5 •IIYes,See Sidebar U1
c Z E
TELEPHONE
Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99
p DRIVER X. PARKED 0 DRIVERLESS 0 PEO 0 PEOAL 0 EWES 0 iiuv 0 NOV 0 DV
yr
o 13-UNDER CARRIAGE 16 1 2 FIRE ID El❑ !� 2 ,�
U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 9 +6.TOP 3 DISTRACTED 0 ® SPDR 0
0 0
SYSTEM IN ENGAGED 15-OTHER 9
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN ` 9 0istrac on Value U1
POINT OF s {I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR MI L_ COM VEH ❑ ® CO
H
Q568750 I L FIRST CONTACT 6 Y__{_ _5 •If Yes,See Sidebar Si)
Z U2 REAR 0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 0
1 G1 BG5SM9G7237212 Bristol West ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Herrera. Nicacia G01104022908 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEATI (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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71
/ / U1 1 D
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EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 06,29 /2025 10 15 ®❑PM 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
2 0 18 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! 0 PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
z
—a ARREST NAME / / ❑PM '
o u ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
,
10
t 2 0 ARREST NAME AM
1 r ❑❑PM ❑Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El - ❑AM Workers present? ❑Y 10
547 Homeier.William 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Foeln
i (b 1. Hasa weight rating more than 10,000 pounds(example:truck or truck/trailer
r }----r----, „m,. INDICATE NORTH combination):or p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or
X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I
A } } O
n.nd.lmzd C - } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
i. 4. Is used or designated to transport between 9 and 15 passengers,including (I)
}--- ----+ — - } } } g po passen rs,includi the driver,
Owl] . • • •
for direct compensation(example:large van used for specific purpose):or O
L — L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
i
placarding(example:placards will be displayed on the vehicle). XI
toss?H7wnd Ii?Rd D
8hermen?HoapldflEm.ry.ncY —I
:Y — d.pat ent CARRIER NAME Z
ADDRESS 'n
w
0
— 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. --- --1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Maroon
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE