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HomeMy WebLinkAbout2025-00050970 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 6 Sheets HUI III 0 IftIl DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV u, 1 U21 3 4 1 U, 1 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* 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-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00050970 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 �1 ® ❑ RELATED ❑Y ®N 08 06 2025 DAM ❑YES ®NO U1 —< RANDALL RD Elgin02:55 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ® STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Johnson.Jocelyn.J. 1 1 / yr 13-UNDER CARRIAGE ©i ! FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 4 m F 2 SY is-OTHER 4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, i�6 �i COM VEH 0 j$J 4 O0 F. FIRST CONTACT 11 7_:—_;__5 *Il sees"See Sidebar U1 Z Oswego IL 60543 0 1 0 P300885 IL 2025 REAR TELEPHONE IL D 0 1 N4BL4CV3KN321444 Progressive ❑v Il N U2 r ni B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m South Elgin Fire 1 99 9 Same 998365437 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D o Other 0 Y El 1 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCv 0 DV !1 9 9 1 M Ford Fusion 2017 00-NONE ,�_' t2 "_, DUE TO CRASH rg ❑ 2 0 13-UNDER CARRIAGE I 2 FIRE ID El U2 C li F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 O O`NT OF 1 6 L'_5 C•IO es BeeSidebarH ❑ ® Ut CO — Chicago IL 60641 0 1 0 DS17844 IL 2025 I 0 Si) IL D 0 3FA6P0H72HR415751 Geico ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 1 99 9 Same 4365818642 BAC E 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 ❑Y U2 Z N 1 El 11 1 co 81 ,12 !25 02 57 ®PM in a Work Zone? ®N DIRP D I T 2 0 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) v L 81 r 12 !25 02 57 ®PM ❑Construction >F Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a, ARREST NAME 81 /12 !25 03 03 ®PM " o U 1 ® 1 1 1 0 CITATIONS ISSUED ❑PENDINGSLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility r 2 0 37 3 ARREST NAME 81 112 125 03 54 ®PM El Unknown work zone type U1 45 n 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 ADDITIONAL UNITS FORMS. 0 A CMV is defined as for vehxae used to tra and: r ----,5-••--, ; any mo nsport passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - } i.-- -;-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I X1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' , } (example:shuttle or charter bus):or X 3. Is . L.___A.. 1 i. <--_... . J transporting edmployeeslin5 hecourseeo theire rsmployment exam pal e:employeener 73} } } • � . transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , < .---_-a-___� , J. , , 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____.I L L L L.__-..i._ 1 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 i. ADDRESS 0 th CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z ) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m Z GVWR/GCWR 1 El <10,000 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI 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 73 IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Gray u 3 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 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE