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HomeMy WebLinkAbout2025-00070983 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 1111 flIII III IflIII III II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO04016O39' u, 1 U21 3 4 1 U1 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 11 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00070983 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 10 31 2025 DAM ®YES 0 NO U1 -< N RANDALL RD Elgin04:13 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W HOLM ES RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ION ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 T�TOWED U1 0mo Goldstein. Ilan. N. Ford Escape 2011 00-NONE ©, >2 >,/OUETOCRASH ® ❑ NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10. • 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 6 m M 2 SYTM IN ENGAGE4 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it S 4 COM VEH ® 0 1 0 F. FIRST CONTACT 12 7 �_; _,__5 *Irves.See Sidebar U1 V Z Crystal Lake IL 60012 0 1 0 EZ61662 IL 2025 REAR TELEPHONE IL D 1 FMCU9DG3BKC23875 Cincinnati Casualty ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same A011169452 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 0 x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 NCV ❑DV yr 13-UNDER CARRIAGE 10'( 2 FIRE 0 El U2 C c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 POINT OF 8 i ' 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�_QI._5 •IfYes.See Sidebar Z Crystal Lake IL 60014 0 1 0 3805159B IL 2025 REAR 0 C Z IL A 7 1 FTFW1 E82PFA87159 Cincinnati Insurance ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Airlift Alliance Contractors EBA 0317038 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs > 71 / ,, U1 1 D 1 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 10,31 l2025 04 13 ®PM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 0 11 1 28 99 ! , 0 PM• ❑Construction * Z 3 0 'xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Goldstein. Ilan. N. 11-601 S1552000211 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 0 AM r 2 0 ARREST NAME 10+31 12025 04 40 ®PM El Unknown work zone type U1 45 nCf 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1552-Thompson.Ahmad Rashad 901 269-Mendiola 11 , 18,2025 01 30 ®PM Workers present? ®N U2 45 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 truckrtrailer -< INDICATE NORTH combination):or p0 �rm� I I ,..., AbT To 6Caw.a1 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C c-^ _ } (example:shuttle or charter bus):or fit X I- ------I----; I I e w - transporting employened to es inthe course passengers5 or fewer hir employd ment example:employee transporter} } } -usually a van type vehicle or passenger car):orCD C L i. --}----; ` R - •} } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or- - - O ----a--- P - 1 L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III placarding(example:placards will be displayed on the vehicle). m A a' I /r1 • CARRIER NAME Z _l�fi 1709 - ADDRESS D I +Me r. Randal (A 0 fi CITY/STATE/ZIP I g 1 1_l MOTOR CARR.ID 0 Interstate El Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn 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 ® 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 ❑No 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 ®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 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 3 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