HomeMy WebLinkAbout2025-00070530 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 III 11 II I1 II IIIIII U I� II fl 1fl H1111111IU1
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004011217-
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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 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00070530 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mS RANDALL RD Elgin12:07
® ❑ RELATED ❑Y ®N 10 29 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W SPARTAN DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ 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
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) mo
/1 9 8 1 Subaru Forrester 2024 00-NONE •
13-UNDER CARRIAGE 11, ,z DUE TO CRASH ❑
101 ! 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®S NE DUNK VEH. 0 AT CRASHD 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 $ iI 6 �i COM VEH 0 j$J 1 0
H 1- PALATINE I L 60074 0 1 0 FIRST CONTACT 1 7 . __5 *II Yes.See Sidebar U1
ZR869197 IL 2025 Ismi
TELEPHONE
IL D 0 JF2SJAEC7EH417088 ALL STATE ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 923406666 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused ❑Y ElN 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 N v 0 DV
!1 9 5 8 Chevrolet Silverado 2013 00-NONE 11_-1 1z--_1 DUETOCRASH ❑ 21 14
o -yr . 13-UNDERCARRIAGE 10;i• c. 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y 10 N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 9 0
POINT OF 8 I 4 COM VEH D ® Ut 03
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �
FIRST CONTACT 7 0 �___s •• •If Yes.See Sidebar C
TWIN LAKES WI 53181 0 1 0 1204389B IL 2025 REAR
0 N
WI D 0 1GCNCPEX3DZ184167 SELECTVE INSURANCE ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 OLSEN TUKPOINTING S2664639 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,29 l2025 12 13 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 03 28 , ! ❑PM ❑Construction *
Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 8
o ® 11 1 ARREST NAME Serra.Steven.A. 11-601-Ax 1558000093 / ! ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
r 2 ❑ ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type 25
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2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1558-Lundvick.John 702 12 ,02,2025 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•---, , IN\
1 A CMV is defined as any motor vehicle used to transport passengers or property and: Z1 g orethan pound ( a p truckortruck trader -<
1. Hasa weightratio m 10,000 5 ex m le:` ` --I -' 1 INDICATE NORTHcomb nation)or` BYARROW2 Is used or designed to transport more than 15 passengers including the drivern t - } (example:shuttleorcharterbus):ort 1 3. Is desgnetl to car 15 or fewer ssen ers and o rated a contract tattler O
- <____A____- 1 1 - i. } } } transport) em to eesinthecourseoftheirem
ry pa 9operated
l ng p y pbyment(example:empbyee � X
t transporter-usually a van type vehicle or passenger car):or w
i. i. __}----l, - 1 - • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
for direct compensation(example:large van used for specific purpose):or
L .I. � _ t l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires O
.D
placarding(example:placards will be displayed on the vehicle).
—1
CARRIER NAME Z
_r_vot7oscaro_J - i. i. __ ADDRESS 'O
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CITY/STATE/ZIP g
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
i ❑ Not in Comm./Govt. ❑ Not in Comm./Other
111 USDOT NO. ILCC NO. 0
73
Source of above 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
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE