HomeMy WebLinkAbout2025-00070917 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® 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$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00070917 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
N RANDALL RD El08:53
® ❑ RELATED ❑Y ®N 10 31 2025 ®AM ❑YES IX]NO U1 —<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT l MI N E S W FLETCHER DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 6 (n
❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NW ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRObff TOWED U1 Q
NAME(LAST,FIRST,M) YEBRA.JASON mot
13-UNDER CARRIAGE 10 i ' 2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 6 4 COM VEH 0 0 2 O
F. FIRST CONTACT 12 7 , _5 *II Yes.See Sidebar U1
Z Wayne IL 60184 0 1 EN58777 IL 2025 is
TELEPHONE
IL D 0 2C4RC1 BGXGR132746 Progressive ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 930 858 131 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 NW 0 i v ❑Dv
/1 9 9 2 Mack Trucks. !Unknown 2014 00-NONE 11 12--_1 DUETO CRASH 0 D 14
oYr 13-UNDERCARRIAGE 10-1 2 FIRE 0 El U2 C
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M 2 4 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 -
POINT OF 8 II 4 COM VEH 0 0 ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 6 �'_
FIRST CONTACT 6 Y__{_Os•_5 •If Yes,See Sidebar
= Rosemont IL 60018-5303 0 1 52201 R IL 2025 REAR 0 N
D
IL A 7 1 M2AUO4CXEM008292 Zurich ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Lakeshore Recycling. Dario BAP01 1 1 54-08 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (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 10,31 /2025 08 53 ®❑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 , , 0 PM ❑Construction *
N 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
—a, ARREST NAME YEBRA.JASON 11-601 260-01768(W) , ! El PM
o N El 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
45
t 2 ARREST NAME AM
7 , r ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
260-Sheehan.Joseph 801 r , ❑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
----{-----; 0 1 1 Not To Scafe 1 - combination):or rating more than 10,000 pounds(example:truck or truck/trailer -I 1. Has a weight
T9 Sc g INDICATE NORTH
1 t BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- i. e. (example:shuttle or charter bus):or
X
---_------1 / ,Randall?Rd. - ; } } } transportinggemployeeo slIn the course of 5 or fewer he r emplrs oyment(example:employee a contract ner X
✓' transportr-usually a van type vehicle or passenger car): r w
L L.___a____� l0 } 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
- Pe ( P 9 Pe or O
L L--_-a-___. I I t i. i i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
F I FlotalmiRa I CARRIER NAME Z
- ADDRESS 0
w
r . . . . 1.
CITY/STATE/ZIP C)0
MOTOR CARR.ID ❑ Inters ❑
I I T I ❑ Not in Cotatemm./GaA. Not inIntrastate Comm./Other
;_...Y._._.; 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 ❑ 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gold Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE