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HomeMy WebLinkAbout2025-00052939 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011001 0101100100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003925613 u, 1 U212 3 4 1 U, 4 U2 1 U, 1 u2 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ 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) El Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00052939 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7 RANDALL RD Elgin ® ° RELATED ❑Y ®N 08 14 2025 ❑AM ®YES 0 NO U1 PRIVATE mo /day/yr 04:27 ®PM FLOW CONDITION m _ 1 Q(� COUNTY PROPERTY ❑Y 2�1 N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ® �C.7!MI 10 E S W Alft Lane WITH VEHICLES INVLD INSTOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 7 0 FOR DAMAGED AREA(S) FRONT TOWED U1 O Laskowski.Anthony. . 0 9 / yr 13-UNDER CARRIAGE ©i O-O FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED ® 0 U2 7 m M 2 5 ❑Y ®N SYSTEM VEH. AT CRASH 99-UNKNOWN 9 76•TOP 3 `Distraction Value 7 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;iI S • 4 COM VEH ❑ 1� 1 0 ~ Lake In The Hills IL 60156 B 1 0 FIRST CONTACT 12 7_;1 _5 *IIYes.See Sidebar U1 Z3860464B IL 2025 REAR TELEPHONE IL C 1 FTZR45E35PA82510 National General ❑Y igi N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 2030338044 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 71 g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 /1 9 9 1 Jeep(after 198�)npass 2020' 00-NONE 0i Qi-O DUE TO CRASH ❑ 2 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C li F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 POINT OF 8 i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QIOS •It Yes.See Sidebar C Lake In The Hills IL 60150 A 1 0 CG14852 IL 2025 aR0 Si) IL D Geico ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Same 6194938103 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Sherman RESPONDER u1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 05 / D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 08/14 /2025 04 27 ®AM 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) o" 2 ❑ 28 99 / / ❑PM• ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o ® 1 1 1 ARREST NAME Laskowski.Anthony. R. 11-601 S1552000152 / / El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility t 2 0 1 1 1 ARREST NAME 08/14 /2025 05 31 ®AM 45 PM El Unknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1552-Thompson.Ahmad Rashad 901 391-Jacobucci 09 / 16/2025 01 30 ®PM AM Workers present? ®N U2 45 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 r ----r•---, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z r 1. Hasaor more than pounds(example:truck or truckrtrarler 1. Hasa weight rating10 000 i INDICATE NORTH combination): -< N7RarnE°Y7RG BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - (example:shuttle or charter bus):or 0 r r r X A F 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O T1 } } 1- . transporting employees in the course of their employment(example:employee y a van type i. ...l. III. ID 1C transporter sedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,includingthedrrver, } } . for direct compensation(example:large van used for specific purpose):or No!To Scale .D < <____a____� t } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires i Ni. y placarding(example:placards will be displayed on the vehicle). XI J CARRIER NAME Z 4 __ ADDRESS w C) CITY/STATE/ZIP g MOTOR CARR.ID ❑ Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other 00 I I I I - USDOT NO. ILCC NO. m�q Am. Z1 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 to 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 Green Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE