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HomeMy WebLinkAbout2025-00059595 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I011011001 OIH III 1111111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03954064 u, 1 U21 3 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 4 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00059595 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m ® ❑ RELATED ®Y 0 N 09 10 2025 ®AM ❑YES ®NO U1 -< E CHICAGO ST Elgin10:46 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W VILLA CT COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n Robinson. Randy. L. 11 / yr 13-UNDER CARRIAGE ©,I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 9 ALGN = ❑ CI N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I,I,.4 COM VEH ® 0 1 0 ~ Mayfield KY 42066 0 1 FIRST CONTACT 00 7_: __5 *I(Yes.See Sidebar U1 Z Yf P1139235 IL 2025 REAR TELEPHONE KY Other 7 4V4NC9EH4PN620612 Brickside ❑Y igi N U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 17166 1 rn o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 98 0 p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0 i v 0 DV !2 0 0 5 Jeep(after 196�)npass 2003 00-NONE ,011 12 (,-2 DUE FIRE O CRASH 0 ® U2 2 C o mo 13-UNDER CARRIAGE III c M 2 4 SYSTEM IN ENGAGED 15-OTHER 9.1,6•TtOP 3 9 0 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Oistractlon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 j1:, 4 COM VEH ® 0 U1 W FIRST CONTACT 5 7_ _,L_5 •If Yes.See Sidebar = ELGIN IL 60120 0 1 DB58817 IL 2025 REAR 0 IL D 1 J4G L48K53W644978 All State ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 802259764 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 El 11 1 09,10 l2025 10 46 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 ,, v 2 ❑ 2 06 09 r 10 l2025 10 46 ❑PM ❑Construction * R O 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 3 ®AM ❑Maintenance U2 a1 ® 11 1 ARREST NAME Robinson. Randy. L. 11-601 387-1250 09,10 l2025 10 46 ❑pM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 30 T 2 0 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 cf n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 30 387-Root. Mark 101 , ! ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is . L.___A_. 1 i. ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , 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 0 L L___-a____.: L L L ...._-..i.____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zt —D7 CARRIER NAME Same as Owner Z i. ADDRESS 0 T. 1 CITY/STATE/ZIP I n MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . 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 ® 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. WIDELOAEP 0 Yes ®No 2 TRAILER VIN 1 1 UYV52538H2041606 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ® 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. w White Red u 1 TOWED TOTAL VEHICLE LENGTH 5 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE 9 LOAD TYPE 5