HomeMy WebLinkAbout2025-00050970 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003914099
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00050970 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
® ❑ RELATED ❑Y ®N 08 06 2025 DAM ❑YES ®NO U1 -<
RANDALL RD Elgin02:55
_ _ g PRIVATE mo /day/yr N PM FLOW CONDITION m
FTlMI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) mo
1 9 4 7 Ford Escape 2014 00-NONE •
13-UNDER CARRIAGE ,1, ,zT DUE TOCRASH ® 0 E
! FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 4 M
M 2 4 ❑Y ® n is-OTHER
SYSTEM
❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN x
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i, a �i,4 COM VEH 0 j$J 4 C)
~ ELGIN I N I L 60124 B 1 0 FIRST CONTACT 1 (1)_; _-5 *If Yes.See Sidebar U1 0
ZFJ34943 IL 2025 REAR
TELEPHONE
IL D 0 1 FMCUOGX5EUE38318 USAA ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 Same GICO260286947101 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph 0 Y ® N 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0 I v 0 Dv
yr 13-UNDER CARRIAGE 10'( 2 FIRE 0 El U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraetlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i S l;, 4 COM VEH 0 N ut CO
FIRST CONTACT 7 O7 �_ ==Q�:._5 •If Yes.See Sidebar
Z South Elgin IL 60177 0 1 0 AT78860 IL 2025 REAR 0 Si)
M
IL D 0 5NPE24AF9FH226284 American Alliance ❑Y N N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same I LAA087981803 BAC
$
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),(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
u N 1 ® 11 1 81 ,12 ,25 02 57 ®PM AM in a Work Zone? ®N DIRP D
co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 0 11 1 28 17 81 ,12 ,25 02 57
®PM• ❑Construction *
N 3 0 11 1 igI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
J ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Hanson.James. R. 11-601 1558000033 81 ,12 r25 03 03 Igi pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
T 2 0 ARREST NAME 81 )12 125 03 54 N PM ElUnknown work zone type U1 45
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1558-Lundvick.John 702 269-Mendiola 91 , 12 ,25 09 00 ❑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
r ----r••--, , / ;' / - - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
ADDITIONAL UNITS
-<
` ` -'- -' / 111/
r INDICATE NORTHatiowen)i:gohrt
rating more than 10,000 pounds(example:truck or truckMailer Z
1 1.
! N
! i BY ARROW 2 Is used or designed to transport more than 15 C
` 1 � g sp passengers including the driver
L ! ,. (example:shuttle or charter bus):or X
-— / %�= 3. Is designed tocarry15 or fewer passengers and operated a contract carrier I 0
< --___A---.; i ,�/ - y } } } transportinggemployees In the course of their employment NOf 70 SCBJe
ployment(example:employee
,.m, - , , transporter-usually a van type vehicle or passenger car):or co
L L.___a.._.1 r� } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. CO
/ A I. for direct compensation(example:large van used for specific purpose):or to
L L..__a..... `.' i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
;,r 7J placardig(example:placards will be isplayed on the vehicle). D i
11°'I , CARRIER NAME
t
y !$,` ADDRESS 0
`:r h u/i
1 1 CITY/STATEJZIP n
` - MOTOR CARR.ID 0 Interstate El Intrastate
l I r l ` ❑ Not in Comm./Govt. ❑ Not in Comm./Other
'r USDOT NO. ILCC NO. C
m
Xl
Source of above 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
Red Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE