HomeMy WebLinkAbout2025-00073096 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 0110 ll 1111
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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 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00073096 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 m1500 N RANDALL RD El In10:25
® ❑ RELATED ❑Y ®N 11 12 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRO T TOWED U1 0
Allen.Jordan.C. 1 0 /
yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOR 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 iI 6 i} 4 COM VEH 0 El 1 00
F.
Lynwood I L 60411 0 1 0 FIRST CONTACT 5 7_;L Q--5 *II Yes.See Sidebar U1
Z Y 206062F IL 2026
TELEPHONE
IL C 7 JALC4W164K7007615 National Liability and Fi ❑Y ign4 U2 13 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 73APB009778 1 rn
"o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 98 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 N4v 0 NCv 0 Dv
yr 0. 12 _ C
Ti 13-UNDER CARRIAGE 10 I z FIRE ID El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED ®-OTHER 9.1,6-TOP 3 ❑ ® SPDR 0
❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracii n Value U1 3
POINT OF 8 .;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 15 Y =1'�=5 COM•I Ysee Sidebar❑ ® CO
~ C
FA97003 IL 2025 REAR0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
J F1 G PAC65E8317299 USAA ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
Same 0232275817102 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPOND❑Y 0N Ui =
(UNIT) t SEAT I (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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AGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 11 ,12 l2025 10 25 ®❑pm AM in a Work Zone? ®N DIRP D
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 20 1 1 ❑PM ❑Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
❑AM ❑Maintenance U2
o1 ® 11 5 ARREST NAME Allen.Jordan.C. 11-601-Ax 298001337W ! ! El PM SLMT
o Nu 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
00
t 2 0 ARREST NAME AM
1 r ❑❑PM ❑Unknown work zone type U1
nCf T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 00
298 Lopez, Mirko 901 , ! ❑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
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
c ` -'- ' r INDICATE NORTH combination):or —I
1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
t- (example:shuttle or charter bus):or 0
—ND r r
7,77)„.51111.;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
-- - } } } transporting employees In the course of their employment(example:employee X
Not To Scale I transporter-usually a van type vehicle or passenger car).or Dp
4. Is used or desi nated to trans rt between 9 and 15 ge ng cC/t
} } for direct com nsation exam I lar a van used fors �cifice ur rs'mdudi [he driver,
Pe ( P 9 Pe p pose):or �
XI
t l. . 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
'mD"191inm1°"'� pWcartling(example:placards will be displayed on the vehicle). m
:- :- ":" 1 i 1
—1
CARRIER NAME Z
ADDRESS 0
m.�nrrd D
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
'
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
White Blue.Light
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE