HomeMy WebLinkAbout2025-00067941 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011001 III 1111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00399:948
u, 1 U21 2 4 1 U116 U2 1 U, 1 U2 1 U, 1 U2 1 1 10 U1 4 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q 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
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 2025512025-00067941 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mSPARTAN DR Elgin 02:27
® ❑ RELATED ®Y 0 N 10 17 2025 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W S RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Egl 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 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRO fir TOWED U1 Q
NAME(LAST,FIRST,M) mo
!1 9 9 8 Chevrolet Silverado 201 5 00-NONE 11' O i DUE TO CRASH ❑ EN
13-UNDER CARRIAGE 10:r 2 ' 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 :il 4 0
F. FIRST CONTACT 12 7_ 6 _-5 *II Yes.See Sidebar U1 COM VEH 0 Ea 1
Z GILBERTS IL 60136 0 1 0 3535594B IL 2026 I ,
TELEPHONE
IL B 0 1GCVKREC1FZ310296 PROGRESSIVE INSURANCE ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 986131245 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEON. 0 EWES 0 NMv 0 NOV ❑DV
0 0 0 Hyundai Tucson 2025 00-NONE 11_"j t2..-_1 DUE TO CRASH ❑ !g 2 x
o y yr 13-UNDERCARRIAGE tal 2 FIRE ❑ El U2 C
Ti
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y lYi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI 6 l',_4 COM VEH D ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See SidebarC
H HAM PS H I R E I L 60140 0 1 0 FL85758 I L 2026 FIRST 0
Z
IL D 0 SNMJCCDE2SH587307 GEICO ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 6225339404 BAG E
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 ® 11 1 10,17 l2025 02 27 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 ❑ 28 99 + ! ❑PM• ❑Construction *
1
Z3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
o1 ® 11 1 ARREST NAME Bajorek. Eric. L. 11-601 1551000229 / ! El Pm SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
r 2 ❑ ARREST NAME 10 r 17 12025 02 27 ®PM ❑Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1551-Dede.Joseph 801 11 / 18,2025 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 truck trailer -<
' 0 r INDICATE NORTH combination):or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
Not To Scale X
3. Is designed to}- A i carry15 or fewer passengers and operated I a contract carrier O
--- ----
;`N?Rendeq?Rr1.� - }} } transporting employee � �In the course of their employment(example:employee X
----------- transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L ♦— t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
' placarding(example:placards will be displayed on the vehicle).
0
Unit 1 CARRIER NAME —I
Z
ADDRESS 0
C)
CITY/STATE/ZIP g
���� _ MOTOR CARR.ID ❑ Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 USDOT NO. ILCC NO. m
XI
Source of above z
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
a
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black White
u 1 TOWED TOTAL VEHICLE LENGTH 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE