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HomeMy WebLinkAbout2025-00061495 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 001111111 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xoo3969832` u, 1 U2 1 1 1 U199 u2 u, 1 U2 U, 1 U2 4 4 u, 1 U2 *P 0119* 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 2 VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED yR 202512025-00061495 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 09 19 2025 ®AM ❑YES ®NO U1 -< N RANDALL RD Elgin mo /day/yr 02:44 ❑PM FLOW CONDITION m �O C.'J!MI N E O W North Brookside Dr COUNTY PROPERTY ❑Y ® N DOORING ElY #OF MOTOR ❑SLOW Cl) 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 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Hodge.Cassandra. L. 03 / yr 13-UNDER CARRIAGE © IE 10,I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ Ea U2 m F 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COIN VEH 0 Ea 1 0 0 Fl Lake In The Hills IL 60156 0 1 0 FIRST CONTACT 11 7_: __5 *IIVes.SeeSidebar U1 Z DY17454 IL 2026 REAR TELEPHONE IL D KM8K3CA36PU006927 State Farm ❑Y Il N U2 r ni B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 0216695SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr ,2 - C o 13-UNDER CARRIAGE 10.i t, 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value U1 9 - POINT OF 8-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA -5 C•IO e1sVEH •Sidebar❑ ❑ C CO F` pEAR` SeeC M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 15 1 State of Illinois Deer 91 /91 )025 02 44 ®❑pM AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 50 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v t 2 ❑ 37W777 ROUTE 38 150 SAINT CIHARLES 60175 21 99 ! ! ❑AM El Construction >F Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 - ❑Utility a, ARREST NAME ! ! El o u 1 ❑ 0 CITATIONS ISSUED ❑PENDING SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME AM U, 45 r 2 ❑ ARREST NAME 91 !91 /025 03 20 [M PM ❑Unknown work zone type n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y 2 3 ❑ 1 554-Wagener.Vincent 800 363-Vartanian ! ! ❑❑PM Workers present? ®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 al ADDITIONAL UNITS FORMS. r ----r•---, , `J A CMV is defined as any motor vehicle used to transport passengers or property and: Z -lf2L13, -' 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ' }---''-- ' 1 _ amide - r INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ - } (example:shuttle or charter bus):or 0 . A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O 1 } I- I- transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y I. } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L L L I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p -1 CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP 0 0 - MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r ❑ Not in Comm./Govt. 0 Not in Comm./Other -"---- --1 - USDOT NO. ILCC NO. rn N.?Randall?Rd xi Source of above z . GVWR/GCWR m 0 <10,0oo 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = 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 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown E 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'; 0 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 Z ill TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE