Loading...
HomeMy WebLinkAbout2025-00060661 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 0111111 0 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00396.401 u, 1 U21 1 1 1 U, 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 3 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2025I 2025-00060661 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED 0 Y ®N 09 15 2025 ❑AM ❑YES ®NO U1 -< S RANDALL RD Elgin03:33 _ _ 9 PRIVATE mo /day/yr ®PM FLOW CONDITION m l O !MI N E S W HO S Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ® pp Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ® 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 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 5 ! yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 SY4 ❑Y ®SNE❑LINK VEH. 0 AT CRASH IN ENGAGED0 99-UUTHER NKNOWN 9 16-TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4 COM VEH ❑ Ea 1 0 ~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *If Yes.See Sidebar U1 Z FQ60503 IL 2026 TELEPHONE GA D 0 3HGGK5H83FM703051 Progressive ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 992055391 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 New 0 i v 0 DV !1 9 yf 8 Volkswagen Jetta 2012 00-NONE 11 j 12..-_, DUE TO CRASH ❑ 2 73 0 13-UNDER CARRIAGE 10'( 2 FIRE ID El U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y EQ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0 POINT OF 6 i6.14 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 6 O7 ,�_ -4OS •If Yes.See Sidebar C Z Algonquin IL 60102 0 1 0 EZ58165 IL 2025aR0 Si) Z IL D 0 3VWLL7AJ3CM007348 Geico ❑Y ®N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 6203304297 BAc $ 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 El 11 1 91 r 51 l025 03 33 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 0 28 03 { ) ❑PM ❑Construction * Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 o ® 11 1 ARREST NAME Haggard.Justin. L. 11-601-Ax S1526000667 ! ! 10 PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility 0 AM t 2 0 ARREST NAME 91 +5/ 1025 04 30 0 PM El Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45 1526-Walsh.Jacob 801 10 ,26,2025 01 30 ®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 e 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 —I S?Randall? I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } r r ,. (example:shuttle or charter bus):or 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 5 es pa g pe / } } } transporting employees In the course of their employment(example:employee72 _ I I - transporter-usually a van type vehicle or passenger car):or w 2 } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N 4 for direct compensation(example:large van used for specific purpose):or O __ __ t , _ _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m 1 I 1 . . . . placarding(example:placards will be displayed on the vehicle). D CARRIER NAME ADDRESS T. n / CITY/STATE/ZIP g i/ ii i < _ MOTOR CARR.ID 0 Interstate 0 Intrastate Happa?Rd O 1 I r 1 . ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- ----- — — — — — - USDOT NO. ILCC NO. rn XI Source of above Z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes ❑ No 0 Unknown M 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' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. _Redmons/Owners Residence . 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