HomeMy WebLinkAbout2025-00048764 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II DIII
0110010111 1111 III 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03902352
u, 9 U21 3 4 2 U199 U2 1 U,99 1_12 1 U1 99 U2 1 1 12 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00048764 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ❑Y ®N 07 28 2025 ®AM ❑YES ®
PRIVATE NO U1
N RANDALL RD Elgin mo /day/yr 08:00 ❑PM FLOW CONDITION m
_
�0�!MI O E S W Point Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 Co
Kane HIT&RUN ®Y El N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 5 M
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
M 9 9 ID Y CI N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_i L a 4 COM VEH 0 Ea 1
I... FIRST
9 FIRST CONTACT 99 7_: _-5 *II Yes.See&debar U1 0
Z UNKOWN ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
Unkown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR cn
99 9 Same Unkown 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
,F, D Y°N0 N 0
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑,My ❑KCv ❑DV
/1 9$0 BMW Xl 2025 00-NONE 'o,� 12 c,-2 FIRE DUE o CRASH ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF C)'i B iC 4 COM VEH ❑ ® u1
co
FIRST CONTACT 7 Q __, _5 •If Yes.See Sidebar C
Lake in the Fills 0 1 FD41321 IL 2025 REAR0 Si)
Z
IL D 0 WBX73EFO1 S5216006 Progressive ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same 983424889 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 0 Y U2 Z
N 1 ® 11 1 07,28 /2025 08 00 ®❑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 C)
2 ❑ 20 28
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING ( 1 ❑PM El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 5
-a, ARREST NAME ( / ID PM '
oN ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
r 2 ARREST NAME AM
( 1 ❑❑PM ❑Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1563-Rodriguez.Carlos 502 - / / ❑AM Workers present? ❑Y
❑PM ®N U2 50
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
nvrt neumee 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
- - comab ): —Ii- }-- _r- --; I I }
INDICATE NORTH
BY ARROW 2 Isbin usetd onr deorsigned to transport more than 15 passengers including the driver C
} I I - } (example:shuttle or charter bus):or 0
-----A---.-
I _Not 7b scat J 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
sually
van
v
hicle or passenger car):or 07
< <.___a____� I 0 . } 1 transporter4. edoUd slii nattedto rranse rtbettween9and15 a sen ers,includigthedriver, C
} }
\ } } for direct compensation(example:large van used for specific purpose):or O
L I---_-a I~I~s. t — - < I. I 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
j — — placarding(example:placards will be displayed on the vehicle).
r Parrt?alvd CARRIER NAME Z
— — — — - ._ ADDRESS 0
D
I [ -.
I I I-
CITY/STATE/ZIP n
I III
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I ❑ Not in Comm./Gout. ❑ Not in Comm./Other 00
� "Y""' I I I E USDOT NO. ILCC NO. C
m
I I Source of above z
. 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
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
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 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