HomeMy WebLinkAbout2025-00068110 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00399:940
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-0006811 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 10 18 2025 ®AM ❑YES ®NO U1 —<
RANDALL RD Elgin 10:20
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1
FT l MI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 3 /
yr 13-UNDER CARRIAGE 10) O,._2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 (<Tl
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _
0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH 0 ❑ 1 0
~ ELGIN I N I L 60124 0 1 FIRST CONTACT 12 7 ;1 _5 *If Yes.See Sidebar Ut
Z51315EL IL 2025 Ismi
TELEPHONE
IL D 0 WA1 VAAG E2KB008015 Progressive ❑Y Il N U2 (TI
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 9969 46 567 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 eu
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEON. 0 EWES 0
� /1 9 6 8yr Toyota Prius 2017 00-NONE 1i_"i 12--_, DUETO CRASH 0 D 2
o 13-UNDER CARRIAGE 10;1 2 FIRE ❑ ❑ U2 C
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M 2 4 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac) n Value 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
iII 6 ..,_4 . 0000
•IfYes.SeeSidebar
~ 60110 0 1 CX59835 IL 2025 REAR 0 (C/)
M
IL D 0 L16216168138 Geico 0 Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 4217 55 07 65 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
1 6 03 /
:A
/ / UI 2 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,18 /2025 10 20 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 03 28 / / ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
—a, ARREST NAME Sieberg. Megan. L. 11-601 260-01762(W) / / ❑❑PM ❑Maintenance U2
o N ® 11 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
45
r 2 ❑ ARREST NAME AM
T / / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ❑AM Workers present? ❑Y 45
260-Sheehan.Joseph 801 / / ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� J transporting employened to es inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
co
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
xi
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 g
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Blue
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE