HomeMy WebLinkAbout2025-00056393 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1 011011001001
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003939409
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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 1
VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00056393 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
S RANDALL RD El In 11:25
® ❑ RELATED ®Y 0 N 08 28 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 (/)❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n
0 9 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE 0
•
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 6 m
M 2 SY n is-OTHER
4 ❑Y ONM❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1
Z CF28173 IL 2025 REAR
TELEPHONE
IL D 0 J F1 G PAD63DH852984 Geico ❑Y ®N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 6014914805 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m v 0 KCV 0 Dv
1 9 9 9 Nissan Versa 2016 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C
o Yr 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S t 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 O7 ,__Q-,C.
If Yes.See Sidebar C
Z SOUTH ELGIN I L 601772824 0 1 0 EW90495 I L 2025aR Si)0
n
IL D 0 3N 1 CN7AP8G L871389 Geico ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Smith. Michael. D. 4529250815 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SART) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMco
AGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 81 /81 /025 11 25 0 PM AM in a Work Zone? ®N DIRP D
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
2 ❑ 28 18 81 /11 /025 11 25 ❑PM ❑Construction
*
R O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ®AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Solis.Jose. M. 11-601-Ax 1560000074 81 /81 /025 11 25 ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM 50
t 2 0 ARREST NAME 81 1 81 /025 11 45 MPM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
1560-Jones. Bennett 901 10 , 71 /025 09 00 ❑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
a.vrrrwnntd. ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
II I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -
i- }--__r-_--; } INDICATE NORTH combination):or —I
p1
u„ ai I I I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
II I ,. (example:shuttle or charter bus):or
- ------I----; I _ I I I I transporting mployeened to sl5 or fewer in the course passengers thir emplod yment example:employeener X
transporter-usually a van type vehicle or passenger car):or w
} } }
4. Is used or designated to transport between 9 and 15 passengers,including (I)
}--- ----+ �/ - } } } g po pafic purpose):
rs,includi the driver,
unaz for direct compensation(example:large van used for specific p or O
L i.____a____. t i. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
i+ placarding(example:placards will be displayed on the vehicle). ,Zmt
— — - —I
CARRIER NAME Z
ADDRESS 0
V)
CITY/STATE/ZIP 00
I
I _ MOTOR CARR.ID ❑ Interstate ❑ Intrastate �
Not To Scale ❑ ❑
. A Not in Comm./GaA. Not in Comm./Other
�""Y""4 N USDOT NO. ILCC NO.
O
m
XI
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
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
Maroon Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Artier/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE