HomeMy WebLinkAbout2025-00057917 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II DIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03945352*
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INVESTIGATING AGENCY DAMAGE TO ANY El 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 7
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00057917 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
825 S RANDALL RD El 10:55
® ❑ RELATED ❑Y ®N 09 03 2025 ®AM ❑YES ®NO U1 —<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION M
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 0 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Chalupnik.Susan. M. 1 1 /
yr 13-UNDER CARRIAGE 161 !-. 2 FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 0 i n
F 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 •Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i! 6 Lr.4 COM VEH 0 0 1 C)
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 5 7 ; _O •II Yes.See Sidebar U1 0
Z CQ73874 IL 2026 REAR
TELEPHONE
IL D 0 J M 1 BK343741200219 Progressive ❑Y igi N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 957754585 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 e v ❑Dv
/1 9 5 2 Tesla Y 2026 00-NONE O,' t2 "_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 9 U1 0
POINT OF 8 i1�I 4 COM VEH ❑ ® CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 11 7 _, _5 •If Yes.See Sidebar
— Platteville WI 53818 0 1 0 BAU4468 WI 2026 RFJ 0 N
WI D 0 7SAYGDEEOTF363613 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 1104982-SFP-49 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DM (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 11 /
:A
/ / UI 1 D
/ / 2 O
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 5 09/03 /2025 10 55 ®❑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
0
1
2 0 30 99 / / ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o1 ® 11 5 ARREST NAME Chalupnik.Susan. M. 11-407-A W1538000306 / / ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
t 2 ❑ ARREST NAME AM
7 / / pM El Unknown work zone type 10
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1538-Estrada. Leticia 700 397-Jones / / ❑❑PM Workers present? ®N U2 10
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 truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
0 _ } (example:shuttle or charter bus):or
X
Not 7b Scale 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier 0
} } } 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__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
I Pe ( 9 Pe or
O P
0 L s s _ 5. Is any vehicle used to transport anyhazardous material(HAZMA that requires m
placarding(example:placards will be displayed on the vehicle). XI
M
1 B __ D
"'Ma k 8 CARRIER NAME Z
' i 1 ' __ 1 ADDRESS 0
i w
o
i CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; - USDOT NO. ILCC NO. m
XI
Source of above z
'
. 0 Yes 0 No ❑ Unknown A
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
Silver Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 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