HomeMy WebLinkAbout2025-00058025 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II IIIIII 01100101111111 111111111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003945872'
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00058025 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN RANDALL RD El In05:34
® ❑ RELATED ❑Y ®N 09 03 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W FOOTHILL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 1 U.)❑ Cook 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
NAME(LAST,FIRST,M) Unknown.O. mo / / yr Honda CRV 00-NONE „_ O i-, DUE TO CRASH ❑ ❑
13-UNDER CARRIAGE 10 ' 2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 10 <<T1
SYSTEM IN ENGAGED 15-OTHER 9 16.Top 3
9 9 ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN •
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL S 4 COM VEH 0 0 1
I- 0 9 FIRST CONTACT 12 7_: __5 *II Yes.See&debar U1 0
Z UNK REAR
' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
UNK ❑Y ❑N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 UNK. UNK UNK 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
. Refused RESPONDER
PO E X
t 99 0
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑IIIAV 0 NCv ❑Dv CIRCLE NUMBER(S) U1
'1 9 9 1 Honda Civic 2018 oo-NONE ,t"1 12--_, DUE TO CRASH ❑ C 2
o Yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S .. .4 COM VEH ❑ ® Ut co
FIRST CONTACT 6 Y__1_ -5 •If Yes.See Sidebar
H E LG I N IL 60123 0 1 0 AW80189 IL 2018 REAR 0
M
IL D 0 19XFC2F53J E030070 State Farm ❑Y J N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3525814SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 0 Y U2 Z
u 1 ® 11 1 09 103 l2025 05 34 ®AM 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 C)
2 ❑ 28 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + / 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME ! ! ID PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
AM45
7r 2 ❑ / 1 ❑❑PM 0 Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1515-BellEck.Stacy 602 , / ❑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 ADDITIONAL UNITS FORMS.
r ----r••--, , N - A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I ntot Ta sowsHasweightratingmore than pound (example:truck or truck trailer
J ....
l q�I 1. bia 10,000 5
i- }---_r----; 0 ( combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A — — 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } 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 y— — - } } • •
for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L — t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
a placarding(example:placards will be displayed on the vehicle). m
_ ! __ 0 D
\ I I CARRIER NAME
ADDRESS 0
V)
I I
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
0
USDOT NO. ILCC NO. m
I I Xl
m
Source of above z
. • m
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
11
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Green Silver
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE