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HomeMy WebLinkAbout2025-00068561 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII II II 101111 lID II III 0 DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X0040D0787- u, 1 U2 1 1 1 U116 u2 U, 1 U2 u, 5 U2 1 6 U1 15 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 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 3 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00068561 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r7 2000 N RANDALL RD El In 11:39 ® ❑ RELATED ❑Y ®N 10 20 2025 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl) ❑ FT/MI N E S W 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 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 MAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 FOR DAMAGEDAREA(S) FROr4T TOWED U1 Q Perez Gaspar. Israel 0 7 / yr 13-UNDER CARRIAGE ©1 ! 2FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rn M 2 4 ❑Y ® n is-OTHER SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 t6•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i, a �i,4 COM VEH 0 Ea 2 0 ~ 60110 0 1 0 FIRST CONTACT 1 O7 _; __5 *Irves.See Sidebar U1 0 Z EE40020 IL 2026 REAR TELEPHONE IL D 4F2YZ04114KM15365 United Security ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same USI 928455-03 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 0 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0 NAv 0 NCv 0 DV yr 12 _ C1 o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ ❑ SPDR 0 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 9 - POINT OF s-.;, -4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—d:-9 COM•I sVEH •Sidebar❑ ❑ C CO F` ----- CO See M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF 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) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 1 3 10 / F 2 4 0 1 U2 R1 ##occs > / / / / UI 2 D / / 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 36 1 10,20 /2025 11 40 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 453. T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 22 3 10 99 ! / ❑PM• ❑Construction * Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / ID PM ' o N 1 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 45 t 2 ARREST NAME AM 7 ! / ❑❑PM ❑Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y -2 3 0 ❑AM Workers present? ❑ 327 Hromadka.Scott 502 ! / ❑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 -< i- ----_r_-_-; combination):or INDICATE NORTH 0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - - } (example:shuttle or charter bus):or 531 ; /,__/r� 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O a- - } } } transporting employees in the course of their employment(example:employee 73 1 transporter-usually a van type vehicle or passenger car):or w < <. a I I r_._ 4. Is used or desi nated to trans rt between 9 and 15 ssen rs,including the driver, • C } } for direct compensation(examp large van used for specific purpose):or 0 L L_._-a..... + - l. t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m pWcartling(example:placards will be displayed on the vehicle). ;prt - CARRIER NAME Z ADDRESS 0 T. rn t ! ■ CITY/STATE/ZIP g Not To Scale ( ,T' i. MOTOR CARR.ID 0 Interstate El Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other 0 USDOT NO. ILCC NO. C XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI 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 ❑ 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 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Other/Unknown SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE