HomeMy WebLinkAbout2025-00042099 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011000 0
l0I 0 II
100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003873163
u, 1 U21 1 1 1 U, 4 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY [8]OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00042099 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 07 01 2025 ®AM El YES ®NO U1 -<
S RANDALL RD Elgin 11:48
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
15 !MI N E S W HO S Rd COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 Cl)
® pp Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EWES ❑NW ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 6 /
yr 13-UNDER CARRIAGE 10.I , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 SY n is-OTHER
4 ❑Y ®SNE M DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 C 1 0 FIRST CONTACT 12 7 ; __5 *Irves.See Sidebar U1
Z443750 IL 2025 E
TELEPHONE
IL D 1 3CZRU6H53GM722739 State Farm ❑Y ®N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Berna. Michael.J. 2259721-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑Nuv 0 KV ❑DV
/1 9 9 6 Ford F150 2022 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon value 9 g
POINT OF S 1 it COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �J 5
FIRST CONTACT 5 7. _,LDS •If Yes,See Sidebar
Hampshire IL 60140 0 1 0 3903482B IL 2025 REAR0 C
IL D 0 1 FTFW1 E59NKD00182 Country Financial ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same PA8873454 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 07/01 /2025 11 48 ®❑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
v 2 ❑ 28 99 07,01 /2025 11 52 ❑PM ElConstruction *
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Berna. Kathleen.C. 11-601-Ax W1538000270 07/01 /2025 12 00 0 PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
0 AM
F 2 ElARREST NAME 07/01 /2025 12 24 ®PM ElUnknown work zone type U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1538-Estrada. Leticia 700 237-Copland , / ❑❑PM Workers present? ®N U2 45
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
_Not To Seale ADDITIONAL UNITS FORMS.
r ----r•---, , l Ill : A CMV is defined as any motor vehicle used to transport passengers or property and: Zr .° II 1. Hasa r g ore than pound { a p :truck or truck trailer
1. Hasaweight ratio m 10000 5 ex m le -IINDICATE NORTH tan)o p0BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):orHapps Rd ' 'll 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
• -----------i [._ 14
`
} } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
' $ $ } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
< <. i
for direct compensation(example:large van used for specific purpose):or 0
9 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a �' I placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
s wwrr 0
qd - ADDRESS
D
rn
�5; ot• O
I `= CITY/STATE/ZIP g
- MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 I ❑ Not in Comm./Govt. 0 Not in Comm./Other0
1 1
I • USDOT NO. ILCC NO. m
m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 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? 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
71
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
Gray Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE