HomeMy WebLinkAbout2025-00042029 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463813149`
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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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00042029 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 07 01 2025 ®AM ❑YES ®NO U1
N RANDALL RD Elgin06:49
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
15 !MI N E S W West Highland AveCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (/)
® g Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
Fox.Aaron.J. 0 1 /
yr 13-UNDER CARRIAGE lo I , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M 2 SY5 ❑Y ®SNE M❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�a �i 4 COM VEH 0 j$J 1 C)
f. FIRST CONTACT 11 7_:—__;__5 *irYes.See Sidebar U1
Z ST CHARLES IL 60175-4724 0 1 0 V378661 IL 2026 REAR
TELEPHONE
IL Other 0 1 HGCV3F9XMA009117 Geico ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 4361111505 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
D
Refused ❑Y ® N 2 0
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑row 0 i v ❑Dv
!2 0 0 1 Subaru XV Crosstrek 2.0 2024 00-NONE .1.,-I 12..- , DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10'i 2 FIRE ❑ El U2 C
M 2 4 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value
POINT OF s 1.6) 4 COM VEH 0 ❑ U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
FIRST CONTACT 6 O7 I._5 •If Yes.See Sidebar
BARTLETT IL 60103 0 1 0 EF60685 IL 2025 REAR 0 C
IL D J F2G UADC8R8910654 State Farm ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Same 3442864-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 1 71 r 12 125 06 49 ❑PM in a Work Zone? ®N DIRP co
1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
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2 ❑ 28 99 + ! ❑PM, ❑Construction *
Z3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
o1 ® 11 1 ARREST NAME Fox.Aaron.J. 11-601 W1555-00008 ! ! El PM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
45
F 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1555 Maldonado. Daniela 901 , ! ❑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
1 e ADDITIONAL UNITS FORMS.
i
rYOt Scale A CMV is defined as any motor vehicle used to transport passengers or property and: Z
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r �....,,.....,
t 1 } 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
combination):or -<
- - —1INDICATE NORTH p1
` ' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
l l - } (example:shuttle or charter bus):or
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L i. ......
A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
1 I. I- I- 3.
employees In the course of their employment(example:employee °
transporter-usually a van type vehicle or passenger car):or C
i.
I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. to
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for direct compensation(example:large van used for specific purpose):or O
, .D_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
_ ADDRESS
V)
C)
CITY/STATE/ZIP g
-I- MOTOR CARR.ID 0 Interstate 0 Intrastate
I I I I ® 0 Not in Comm./Govt. 0 Not in Comm./Other
T 0
; _Y_ g®� I E USDOT NO. ILCC NO. m
I
I
XI
Source of above z
. ❑ Yes ❑ No 0 Unknown M
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 VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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: 2 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE