HomeMy WebLinkAbout2025-00060652 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
011011001 01101 01000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003968490*
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ® B Injury and/or Tow Due To Crash YR 2025I 2O25-00060652 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME
255 S RANDALL RD Elgin03:02 SECONDARY CRASH 15
® ❑ RELATED ❑Y ®N 09 15 2025 ❑AM ❑YES IX]NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 4 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�B 4 COM VEH 0 Ea 1 O
F.
ELGIN I L 60124 0 1 0 FIRST CONTACT 12 7 . _5 *If Yes.See Sidebar U1
ZDA75469 IL 2025 E
TELEPHONE
IL D 0 JTEZA3EH9A201 1 262 n/a ❑Y 0 N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same n/a 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused 0 Y ® N 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 NCv ❑Dv
!2 O 0 1 FR
Honda Civic 2017 00-NONE 1("j 12..-_1_., DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10'( 2 FIRE ID ® U2 C
II
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 6 ./. 4 COM VEH ❑ ® Ut W
F,,, FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.See Sidebar C
ELGIN IL 60124 0 1 0 EU72493 IL 2017aR 0 fp
Z
IL D 0 19XFC2F58HE005093 Farmers Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 547966290 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 995 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 CO 11 5 09,15 /2025 03 02 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 0 18 99 / / 0 PM• ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 5 ARREST NAME Khan.Amira 11-501-A-2 747582 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
r 2 0 ARREST NAME 09/15 /2025 04 00 0 PM El Unknown work zone type U1 10
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 10
1528-Rivera. Kevin 702 10 /08,2025 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
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 -<
` ` ' I
' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
T,
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 }-----}----J. - - - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
- for direct compensation(example:large van used for specific purpose):or
L____a____. — — _ i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M
placarding(example:placards will be displayed on the vehicle).
— — CARRIER NAME Z
— _ - ADDRESS 0
CITY/STATE/ nZIP 0
I
MOTOR CARR.ID 0 Interstate 0 Intrastate
r ...,.,_. °
.� Not in Comm./Govt. 0 Not in Comm./Other
--'-------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
Redmons/Impound Lot Garage . 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