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HomeMy WebLinkAbout2025-00042381 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY *X003674200* u, 1 U21 1 1 1 U116 U2 1 U, 1 u2 1 U, 1 U2 1 1 11 U, 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00042381 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ® ❑ RELATED ❑Y ®N 07 02 2025 ®AM ❑YES ®NO U1 -< N RANDALL RD Elgin08:00 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT l MI N E S W WESTFIELD DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 7 ! yr Dodge Ram 3500(pickup) 2025 00-NONE ©1 0 OUE TO CRASH ❑ NAME(LAST,FIRST,M) 13-UNDER CARRIAGE 10.I 2 FIRE 0 DI E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,;il S 4 COM VEH 0 Ea 1 0 F. Round Lake Beach I L 60073 0 1 0 FIRST CONTACT 12 7_;1 _5 *Irves.See Sidebar U1 Z 196718F IL 2026 REAR TELEPHONE IL D 0 3C63R3GL9RG121727 Captive Resources Insuran El ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Bullfrog Spas CA717791 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ uv 0 !1 9 8 8 Toyota Tundra 2024 00-NONE 'o,1 t2 (,-2 FIRE DUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracl n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & 1 S .t. 4 COM VEH 0 0 Ut CO I. FIRST CONTACT 5 O7 ,�=Q)OS •((Yes,See Sidebar C 60110 B 1 0 2831393B IL 2026 aR 0Si) IL D 0 STFPC5DB1RX057357 None ID ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same None BAc $ 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)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 07,02 l2025 08 08 ®❑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 28 99 1 1 ❑PM, ElConstruction >F R 3 0 ZSI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 a 1 ® 11 1 ARREST NAME Biedzinski.Ashley.A. 11-601-Ax W1512553 / ! El PM SLMT 124 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME NAM El Utility t 2 El ARREST NAME Khomych. luri. M. 3-707 1512554 07102 12025 08 20 [M PM El Unknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45 1512-Juarez-Huichapan.Juan 500 08 ,05,2025 01 30 ®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 truckrtrailer -< c ` -' -' I. INDICATE NORTH combination):or —11 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } I.- } transporting employees in the course of their employment(example:employee X 1-90 transporter-usually a van type vehicle or passenger car):or w C i. <.__-a__-_.I I ntT co _ _ _ _ - I. I. •4. Is used or designated to transport between 9 and 1passengers,includingthedriver, —{ a for direct compensation(example:large van used for specific purose):or Pu nt?oncontact ` ' O t i } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI m . . . . -------------------4 i6 0 CARRIER NAME Z I Not 7b Scab ADDRESS O Z r CITY/STATE/ZIP C i. - MOTOR CARR.ID 0 Interstate 0 Intrastate 5 I I T I I ° Not in Comm./Govt. Not in Comm./Other fi Westeld?Dr , ,_...Y. ._., USDOT NO. ILCC NO. m I . XI Source of above z . xi 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 ❑ 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 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 White Orange u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO: _ . 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