HomeMy WebLinkAbout2025-00051188 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 a Sheets 01111101111 011011001
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003914189`
u110 U21 3 4 1 U116 U2 1 U1 1 u2 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00051188 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 08 07 2025 DAM ❑YES ®NO U1 -<
S RANDALL RD Elgin02:45
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 —I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 0NAME(LAST,FIRST,M) y mo
!1 9 5 9 Chevrolet Cruze 2016 00-NONE 11 O 1 DUE TO CRASH ❑ EN
13-UNDER CARRIAGE 1a.I 2 : 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 3 M
F 2 4 ❑Y ®Nn is-OTHER
SYSTEM❑UNK VEH. ATCRASHD 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI 6 4 COM VEH 0 Ea 2 O
~ ELGIN I N I L 60123 B 1 0 FIRST CONTACT 12 7 ; __5 *If Yes.See Sidebar Ut
Z EE78444 IL 2024 E
TELEPHONE
IL D 0 1 G 1 PG5SB3G7118172 Farmers Group ❑Y ®N U2 M
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 6924515320 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Provena St.Joseph ❑Y ® N 2 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑row 0 KV ❑DV
!1 9 y 2 Subaru Outback 2012 Do-NONE 1i_j 12..- , DUE TO CRASH rg ❑ 2 x
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6
FIRST CONTACT 6 7I- 4 COM VEH 0 ® ut IN
I_5 •IfYes,See Sidebar C
Hoffman Estates IL 60169 0 1 0 P500315 IL 2026 PEAR 0 Si)
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IL D 0 4S4BRCCC2C3237349 Progressive ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 975790961 BAG $
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
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 81 ,12 !25 02 45 ®AM in a Work Zone? ®N DIRP co
1 t 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 0 28 17 81 /12 /25 02 53 ®PM 0 Construction
*
R 1 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Baykan. Irene.A. 11-601 S1542-000382 81 /J2 /25 02 57 Igi pM- • El SLMT
El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
N ❑AM U1®
45
T 2 0 ARREST NAME G RI MALDO.JOSE.J. 6-303-A S1542-000381 81 /J2 /25 03 03 PM El Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME AM Workers present? 0 Y 45
1542 Chafe. Ethan 801 269-Mendiola 91 / 61 /025 09 00 DM 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••--, , Unk 2 ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i I8 I i 1. Hasa weight rating more than 10,000 pounds(example:truck or truckrtrailer 2
i- ;.____r____1 - ( comWrtatlon)or
INDICATE NORTH -1
I nk 1 II I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1 I
_ example:shuttle or charter bus):or C
v tiil ilv v _Nwm Scab i i. e. f T,
L A I ® J 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
` Ii } I• I- transporting employees in the course of their employment(example:employee X
A transporter-usually a van type vehicle or passenger car):or co
' . 4. Is used or desi nated to trans rt between 9 and 15 ssen rs,indudi [he driver. C
:_--- } } } for direct compensation(example:large van used for specific purpose):or
.
< <--_-a-___.I l 4 - - t L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
y ` placarding(example:placards will be displayed on the vehicle). XI-1
1 CARRIER NAME Z
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`w h 1 t t ,o ADDRESS D
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CITY/STATE/RIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. Not in Comm./Other
0 o
� --- "1 - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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
Silver Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® 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: 2 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE
DUE