HomeMy WebLinkAbout2025-00054281 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 I0fl
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003931222
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-00054281 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ❑Y ®N 08 20 2025 ®AM ❑YES ElPRIVATE NO U1
S RANDALL RD Elgin mo /day/yr 07:24 ❑PM FLOW CONDITION m
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®.10 FT/� ON E S W BOWES Rd COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
183 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 06 8
, FOR DAMAGEDAREA(S) FROPtf TOWED U1
Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ia U2 06 M
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_i L 6 4 COM VEH 0 0 1
I— 0 9 FIRST CONTACT 99 7_; __5 *If Yes.See Sidebar U1 0
ZUNKNOWN ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
UNKNOWN ❑Y ON U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 99 0
�{ DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 DV CIRCLE NUMBER(S) U1
yr Q 12 ..� C
O 13-UNDER CARRIAGE I 2 FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 919_TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Distraction Value 9 Ut 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-iI 6 i.- 4 C.OM VEH ❑ ® CO
F„ FIRST CONTACT 11 7� -_rA •If Yes,See Sidebar
60102 0 1 EP56089 IL 2026 I:EaR 0 CC/)
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IL D WA1 EAAFY2P2174750 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 2079120-SFP-13 BAC
$
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)1(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 ® 11 1 08,20 /2025 07 24 ®❑PM 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
2 ❑ 20 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + ) ❑PM El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
—a, ARREST NAME / / El PM '
o u ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
50
f 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
D
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? 0 Y 50
1506-Nunez. Maria 807 , / ❑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••--, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
unm z I Not To1. as a weight rating more than 10,000 pounds(example:truck or truck trailer H
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c }---_-I-----; - combination):or
Scale INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I '—. _ (example:shuttle orcharterbus):or
I. OT,
g �r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
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} } } transporting employee in the course of their employment(example:employee
y a van type
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L L.___a____� I - transporter sed or designated nated to transehrt betweeicle or n9andr 15 passengers,ssen rs,including the driver. C/ ` I. } } for direct compensation(example large van used for specific purpose):or
__ J i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP n
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_ MOTOR CARR.ID 0 Interstate 0 Intrastate
I I II- I. -- - --4. 1 r ❑ Not in Comm./Govt. Not in Comm./Other
0
USDOT NO. ILCC NO. C
XI
Source of above Z
. 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE