HomeMy WebLinkAbout2025-00042462 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003874219
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 2025I 2025-00042462 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
N RANDALL RD El 12:23
® ❑ RELATED ®Y 0 N 07 02 2025 12,-- ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W HIGGINS I NS RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 7 n
0 9 /
yr 13-UNDER CARRIAGE ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) IE
10'. O DISTRACTED 0 ]$I U2 7 m
M 2 4 SY 15-OTHER
❑Y ®N SE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL a !i 4 COM VEH 0 Ea 1 0
~ 60110 0 1 0 FIRST CONTACT 1 7_; __5 *Ir Ves.See Sidebar Ut
Z EN13591 IL 2024 REAR
TELEPHONE
IL D JTN KARJ E7GJ504663 Progressive ❑Y Il N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same 986419685 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y E] N 2 eu
t, x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑lily 0 i v 0 Dv
/1 yr 9 9 3 Jeep(after 19 et•begade 2019 00-NONE 'o.r 12 (,-2 FIREocRASH ® U2 2 C
o 13-UNDER CARRIAGEEl
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN I •0istraOlon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'i- s i1;,_4 COM VEH 0 ® U1 CO
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FIRST CONTACT 7 Q __,�_5 •(ryes,See Sidebar
WEST DUNDEE IL 60118 0 1 0 CS61400 IL 2026 I 0 Si)
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IL D ZACNJABB5KPK31963 Geico ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 6059677150 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 6 03 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 07,02 /2025 12 23 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
O 2 ❑ 25 03 / / 0 PM ❑Construction *
Z 3 ❑ xi CITATIONS ISSUED 8
PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Becker. Michael. P. 11-306 340000142 / / El PM SLMT
o N -
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
r 2 ❑ ARREST NAME AM
7 , / pM El Unknown work zone type 50
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2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
340-Phillips. Kathryn 500 310-Zierk 08 , 12,2025 09 00 0 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.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-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____.: L L L ...._-..:_____� t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE