HomeMy WebLinkAbout2025-00047044 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100001111101 100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003695227'
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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 ®5501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ® 6 Injury and for Tow Due To Crash YR 2025I 2025-00047044 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED 0 Y ®N 07 21 2025 ®AM ❑YES ®NO U1
825 S RANDALL RD Elgin PRIVATE mo /day/yr 08:24 ❑PM FLOW CONDITION m
®10�1/MI N E O W randall rd/bowes rd COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS O
DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NOV ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
0 3 /
Honda Accord 2023 13-UNDERCARRIAGE 10VI
�.-2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 1 r<rl
M 2 SYTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 916•TOP3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH ❑ Ea 1 0
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ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_: _5 *II Yes.See Sidebar Ut
Z CF98226 IL 2025 REAR
TELEPHONE
IL D 0 1 HGCY2F57PA011491 AAA ❑y ign4 U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same AUT700861887 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Refused ❑Y ® N 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑row 0 NOV ❑Dv CIRCLE NUMBER(S) U1
r.
yr 12 _ 71
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac Dn Value 9 0
6 I ' 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i
- all'. VEH ❑ ® U1 toY_ _
FIRST CONTACT 6 _{_O ._5 •(ryes,See Sidebar
— Hanover Park IL 60133 C 1 0 AB54391 IL 2025 REAR 0
IL D 0 1 FMCUOGX5G U B34697 Union ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Kellenberger Plumbin CPA33111350 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 0 Y U2 Z
N 1 ® 11 1 07,21 /2025 08 24 ®❑pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 28 99
N 3 ❑ 0 CITATIONS ISSUED El PENDING • + / ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
-a, ARREST NAME / / ❑PM '
S' N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
r 2 ❑ 15
ARREST NAMEAM
c- 7 ❑PM ❑Unknown work zone type U1
1 / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? 0 Y 15
1531 SchE mbach.Jack 702 , / ❑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 truck trailer -<
i- }____r__--; 1 combination):or
INDICATE NORTH
Ir[1] I
1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1 (example:shuttle or charter bus):or
531
x
Not To Scale 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
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I I - } } } transporting employee In the course of their employment� (example:employee � �
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ �� __ } } } 4. Is used or designated to transportbetween9and15passen rs,includingthedrrver,
C
-")sT,') II for direct compensation(example:large van used for specific purpose):or O
rtx um) t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires -Eli
placarding(example:placards will be displayed on the vehicle). XI
adro. D
CARRIER NAME
- ADDRESS
V)
I I
CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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'; 0 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 White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE