HomeMy WebLinkAbout2025-00052939 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
u, 1 U21 3 4 1 U1 1 U2 1 U, 1 u2 1 U, 1 U2 1 1 11 U1 11 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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) ® B 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 -n
® ❑ RELATED PRIVATE ❑Y ®N 08 14 2025 ❑AM ®YES 0 NO U1 -<
RANDALL RD Elgin mo /day/yr 04:27 ®PM FLOW CONDITION m
_
0(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
231 �C.7!MI O E S W Alft Lane WITH VEHICLESOT,
INVLD ® STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 7 0
FOR DAMAGEOAREA(S) FROM TOWED U1 0
Saenz. Isaiah 0 1 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 7 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®S NE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF &:i, a i. COM VEH 0 )g! 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 6 07 ,:�Q-OS *Ir Yes.See Sidebar U1 0
Z DL1354AA IL 2025 REAR
TELEPHONE
IL D Owners Insurance Company ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire McGrath Nissan 5118894600 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NPAy 0 Ncv 0 Dv CIRCLE NUMBER(S) U1
$ 1 9$4 Lexus IS250 2011 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 .' S .t. 4 COM VEH ❑ ® Ut W
F,,, FIRST CONTACT 6 O7 ,�=QLOS C.
it Yes.See Sidebar C
Z SOUTH ELGIN IL 60177 0 1 0 X959043 IL 2026aR Si)0
M
IL D JTHCF5C24B5046103 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Morales. Bernardo 2088837-SFP-13 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPOND Y ❑N 3 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
UI 1 D
/ / 2 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 08,14 /2025 04 27 ®PM in a Work Zone? ®N DIRP co
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: U1 5 n
T 2 ❑ 11 1
❑AM
N 3 0 ❑CITATIONS ISSUED 0 PENDING + ) _ 0 PM• ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a ARREST NAME / / ❑PM
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
,
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM
t 2 El ARREST NAME 081 14 12025 05 31 ®PM El Unknown work zone type U1 45
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ 1552-Thompson.Ahmad Rashad 901 391-Jacobucci 09 , 16,2025 01 30 ❑❑PM 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 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 -
} }-- -;-- --; } } } r -, , ; ; , 1, ( combination):or —I
INDICATE NORTH X1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' J. , } (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 ...._-..i._ 1 L 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 O
USDOT NO. ILCC NO. m
73
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. P3
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 VIM 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
Blue Blue
u 3 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 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE