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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004017317
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INVESTIGATING AGENCY DAMAGE TO ANY El 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 11
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00071745 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15
® ❑ RELATED ®Y 0 N 11 04 2025 ❑AM ❑YES ®NO U1
S RANDALL RD Elgin PRIVATE mo /day/yr 04:07 ®PM FLOW CONDITION III
�D�F !MI O E S W BOWES Rd COUNTY PROPERTY ®Y 0 N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
(g)DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
0 8
yr 13-UNDER CARRIAGE 1 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 h O DISTRACTED 0 0 U2 1 r<II
M 2 4 ❑Y ®SNE❑ 15-OTHER
UNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 'is•TOPO `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 �i COM VEH 0 Ea 1 0
F. FIRST CONTACT 2 7__c--.i-_5 *II Yes.See Sidebar U1 0
Z ELGIN IL 60124 0 1 0 DL558AJ IL REAR
TELEPHONE
IL D 0 National General ❑Y ISI N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
ANDERSON MOTOR COMPA 2021764911 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
N DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES 0 ivy 0 Ncv 0 Dv
1 9 5 9 General Motorrerrain 2016 00-NONE 11 " 1z' _1 DUE TO CRASH 0 ❑ 2 x
o - 13-UNDER CARRIAGE FIRE ID El U2
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F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
0 Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 0
POINT OF 8 I 4 C.OM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:-_ C
FIRST CONTACT 11 7 , _5 •IfYes,See Sidebar
Loves Park IL 61111 0 1 0 AY57311 IL 2026 RE 0 Si)
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IL D 0 2GKFLVE33G6132046 Progressive ❑Y ®N RDEF Zi
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 989566306 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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 ,04 /2025 04 00 ®PM 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 0 04 15
N 1 3 0 ❑CITATIONS ISSUED 0 PENDING + ) _ ❑PM• ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 8
-a, ARREST NAME / / ❑PM '
1 ® 11 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
t 2 0 ARREST NAME 11 104 )2025 05 00 0 PM 0 Unknown work zone type El AM U1 25
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 25
1519-Bae2 a.Guadalupe 702 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.
S7RanOW7Rd
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•-- --I-- -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
trb
ansporter-usually a van type vehicle or passenger car):or w
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L L.___a__..� r I. } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
} for direct compensation(example:large van used for speific purose):or 0
F a i. i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
® - , "" ,
CARRIER NAME Z
WO lb j O
ADDRESS
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BMWS/RD 1 ` CITY/STATE/ZIP g
_ - i. i. i. i. 4. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I l I ❑ Not in Comm./Govt. Not in Comm./Other 0
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I II
! USDOT NO. ILCC NO. m
XI
Source of above z
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Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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
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
Black Red
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE