HomeMy WebLinkAbout2025-00068893 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X004006540'
u, 1 U21 3 4 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 5 11 u, 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00068893 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED PRIVATE ❑Y ®N 10 21 2025 ❑AM ❑YES ®NO U1
S RANDALL RD Elgin mo /day/yr 07:17 ®PM FLOW CONDITION M
COUNTY PROPERTY ❑Y 21N DOORING ❑Y #OF MOTOR El SLOW 3 Cl)
00 ®/MI N E p W South St WITH VEHICLES INVLD IN STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑wcv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
1 0 /
yr 13-UNDER CARRIAGE 16.) 2 , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ® 0 U2 2 171
M 2 SYTM 5 ❑Y ®SNE DUNK VEH. 0 AT CRASH 99-UNKNOWN 9 76•TOP 3 *Distraction Value 6 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il_6 I,.4 COM VEH 0 Ea 1 0
F• Elgin I L 60120 0 1 0 FIRST CONTACT 12 7 ; _5 *If Yes.See Sidebar U1
Z 9 EF78609 IL 2026
TELEPHONE
IL D 0 4T1 BK3EK5AU609072 American Insurance ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 410927210989 2 17`6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 0 N 2 XI
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES ❑IHAV 0 NOV 0 DV
/1 9 8 2 Honda Odyssey 2016 00-NONE ,�_"j Q1-_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 16/ I. 2 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
POINT OF s iI 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 5 1'
FIRST CONTACT 6 Y__{_O -_5 •IfYes.SeeSidebar
= PINGREE GROVE IL 60140 0 1 0 BM85562 IL 2026 i 0
Z
IL D 0 SFNRL5H65GB101857 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Iebeau. David.A. 0871266SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 6 1 0 /
' D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 10/21 /2025 07 17 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 28 99 / / ❑PM• ❑Construction *
Z 3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a 1 ® 11 1 ARREST NAME Zingre.Athen.T. 11-601-Ax S1924-000503 / / ID PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
S' • El Utility
N 0 AM 45
t 2 El ARREST NAME Zingre.Athen.T. 3-707 S1924-000504 , / pM Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1524-Silva,Jose 702 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
r i r r 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
` ` -I -' I I I I 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
II I I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I I I I is,. ` }} } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or
C
L 4. Is used or designated to transport between 9 and 15 passengers,including w}-----;----; - } } } g Po passen rs,includi the driver,
— — 1 - - - for direct compensation(example:large van used for specific purpose):or
1 r t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires -U
• I I I placarding(example:placards will be displayed on the vehicle). Xl
I I I `� . . CARRIER NAME Z
I I __ ADDRESS
II 1 Willw
I I CITY/STATE/ZIP
Not 7hSeaMJ N.M.ndal/Rd. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Green Maroon
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . 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