HomeMy WebLinkAbout2025-00067881 I LLI NOIS TRAFFIC CRASH REPORT Sheet 1 a Sheets 01111101111 IN 010
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003998059
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ 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$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00067881 VERY
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ❑Y ®N 10 17 2025 E�IAM ❑YES ®NO U1 -<
N RANDALL RD Elgin10:17
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W HIGGINS I NS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
FOR DAMAGEDAREA(S) FROM TOWED U1 0Tian.Yuan 1 0 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
F 2 SY4 ❑Y ®SNEM❑UNK VEH. O AT CRASH O IN ENGAGED15-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4-5 *II Yes.See Sidebar U1 COM VEH 0 0 1 0
F. FIRST CONTACT 12 7 _
Z Woodstock IL 60098 0 1 0 Z920871 IL 2025 r' ,
TELEPHONE
IL D 0 JTMJ FREVSG D185175 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Airlift 99 9 Same 0919558-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m v 0 NOV ❑Dv
'1 9 6 5 Chevrolet Colorado Pickup 2023 00-NONE 11_"j t2--_1 DUETO CRASH ❑ 2 x
o yr 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9 16•TOP 3 9 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI 6 =,_ ❑ ® U1 CO
FIRST CONTACT 15 Y :j_O ._5 •IfYes.COMVEH See Sidecar
H ELGIN Z IL 60120 0 1 0 1573907B IL 2026 aR
C
M
IL D 0 1 GCPTFEK9P1238050 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0576629-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DORM (SEX) {SAPT) (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 ❑Y U2 Z
N 1 ® 11 1 10,17 ,2025 10 15 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
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2 ❑ 28 18 ) ! ❑PM, ❑Construction *
1
Z3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
a ® 11 1 ARREST NAME Tian.Yuan 11-601 1540-366 ! ! ❑PM
I$!CITATIONS ISSUED 0PENDING UtilitySLMT
o NSECTION CITATION NO. ROAD CLEARANCE TIME AM El 50
r 2 El ARREST NAME Tian.Yuan 3-414 1540-367 101 17 l2025 11 30 j PM El Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 50
1540-Allah. Muhammad 901 11 + 18,2025 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
ADDITIONAL UNITS FORMS.
r ----r••--, , N?Rendatl9RD A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- ; I I I _ 1. Hasaor more than pounds(example:truck or truck/trailer
c1. Hasa weight rating10 000 i
INDICATE NORTH Iron) -<
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I I t I - r r r (example:shuttle or charter bus):or 0
< ------;----; I I 1 I I ` transporting3. Is gemned ployeeso Inthe course of 5 or fewer he r emplrs oyment example:employee
a contract rier
I } r } transporter-usuallya van vehicle or... Po type passenger car):orCO
L }-----}----; - 1. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)_ for direct compensation(example:large van used for specific purpose):or
— — — — — — —
L L____a____. 1410011x7RD - � L I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 placarding(example:placards will be displayed on the vehicle). XI
II I E - CARRIER NAME Z
- ADDRESS '0
I I w
CITY/STATE/ZIP 0
I MOTOR CARR.ID 0 Interstate El Intrastate
I I T t N I ❑ Not in Comm./Govt. ❑ Not in Comm./Other O
r r
I toot To Scefe I USDOT NO. ILCC NO. 0
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 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Beige
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
_Redmons/Unknown . 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