HomeMy WebLinkAbout2025-00044512 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463886501
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TWO/
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 for Tow Due To Crash
El AMENDED
YR 2025I 2025-00044512 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 -n
® ❑ RELATED ®Y 0 N 07 10 2025 ®AM ❑YES ®NO U1
S RANDALL RD Elgin08:03
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W SOUTH ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ RED ❑PEDAL ❑EWES ❑KIN ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0
03 /
13-UNDER CARRIAGE K FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 6 m
M 2 4 0 Y ®N SYSTEM
❑UNK VEH. AT CRASH 99-UNKNOWN 9 76•TOPO ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it B jl COM VEH ® ❑ 1 C)
F. FIRST CONTACT 2 7__c--_;-_5 C.10(
U1 0
Z SHARON WI 53585 0 1 2286142 IN 2026
TELEPHONE
WI Other 7 1XKYD48X9FJ456263 PROTECTIVE INS ❑Y ®N U2 m
1E EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
R+L Carriers B-11321 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
t D Y°®N ( U 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑r uv 0 KKv ❑Dv
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o _ 13-UNDER CARRIAGE FIRE ❑ ® U2
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M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 TOP® X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i B 1Y ° COM VEH 0 ® U1 IN
FIRST CONTACT 2 Y��_, _5 •IfYes.See Sidebar C
ELGIN IL 60124 B 1 E170827 IL 2026 I 0 N
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IL D 0 STDFZRBHONS202901 USAA ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 007272147101 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 4 07,10 /2025 08 03 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0
2 ❑ 25 28
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 2
❑AM ❑Maintenance U2
—a, ARREST NAME / / El PM '
oN1 ® 11 `1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,..,Utility SLMT
t 2 ❑ ARREST NAMEAM
7 / / ❑❑PM 0 Unknown work zone type 50
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 50
465-Dorado.Ariana 702 - 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
I pp Z. I d %p 1 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` ' ' I 0 I. INDICATE NORTH combination):or -1
i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
- r r (example:shuttle or charter bus):or C
I I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
l- <----------i
` I. } 1- transporting employee �In the course of their employment(example:employee
I • I ` transporter-usually a van type vehicle or passenger car):or w
L L.___a____.I t I. I. } I. 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
a a for direct compensation(example:large van used for specific purpose):or O
L L..._a____. 8 4 - i. < . 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
g ' placarding(example:placards will be displayed on the vehicle). ;p
D
i.
': pQi CARRIER NAME R+L Carriers Z
I ADDRESS 375 2ND ST
. . D
to
CITY/STATE/ZIP Elgin I I L/60123 o
Not To Scale C
_ i. i. i. MOTOR CARR.ID El Interstate El Intrastate
i. O
r 11 d q 4,4 .0 0 Not in Comm./Govt. 0 Not in Comm./Other 0
�-'-- ----- - USDOT NO. 63391 ILCC NO. C
m
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® 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 ®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 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 636 ft. 2 ft. w
Green Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE El 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: 3 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE 9 LOAD TYPE 9
Arties/Impound Lot Garage —