HomeMy WebLinkAbout2025-00054427 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 I0fl 1111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003935830
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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 2
VEHICLE/PROPERTY El OVER$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and f or Tow Due To Crash YR 2025I 2025-00054427 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S RANDALL RD Elgin06:25
® ❑ RELATED ®Y 0 N 08 20 2025 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W SPARTAN DR COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 1 C)
FOR DAMAGEDAREA(S) FROPtf TOWED EN
U1 0Unknown. Unknown / ! Infiniti G35 2003 00-NONE „ •
12 , DUE TOCRASH ❑
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) U2 2 <
2 4 SYSTEM IN O ENGAGED O 15-OTHER 9 is-Top 3 DISTRACTED 0 _
❑Y ®N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 I,.4 COM VEH 0 E! 1 0
H 0 1 0 FIRST CONTACT 99 7_; __5 *IIYes.See Sidebar U1
ZV557050 IL 2025 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
JNKCV51 EX3M002033 Unknown ❑Y 0 N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Bradford.Curley. R. Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NOV 0 Ixv ❑DV
!1 9 yr 7 9 Dodge Ram 1500(pickup) 2018 00-NONE +i_"i 12..-_, DUETO CRASH ❑ ® 1
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac( n Value 0
POINT OF s iI 4 COM VEH D ® ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - MI'_
FIRST CONTACT 6 Y__{_ ._5 •IfYes,See Sidebar
Z ELGIN IL 60120 0 1 0 2976332B IL 2026 REAR 0 N
IL D 1 C6RR7LTXJS253903 Farmers ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 549031210 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER®N u1 =
(UNIT) (SEAT) (DM (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 01 / F 2 3 0 1 0
m
/ / #OCCS >
71
/ / U1 1 D
/ / 2 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 06 25 ®AM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 n
T
v 1 2 ❑ 28 2 1 1 0 PM ❑Construction
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a, ARREST NAME / / El PM '
o N 1 El 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
❑ 45
t 2 El ARREST NAME AM
T , , ❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 554-Stebbins. Blake 801 269-Mendiola , , ❑❑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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
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
0 ' 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
A }} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.__-a Not To ScaleI } } } •4. Is used or designated to transport between 9 and l passengers,including the dryer, y
} for direct compensation(example:large van used fors specific purpose):or O
L L.._-a____. I y` t 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
- - CARRIER NAME
�,. ADDRESS D
Cam)
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
Black Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE