HomeMy WebLinkAbout2025-00072992 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004028D15
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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 1215501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 Ill NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00072992 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mS RANDALL RD Elgin05:00
® ❑ RELATED ❑Y ®N 11 11 2025 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W BOWES RD COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Galus.Jaroslaw 1 2 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 3 ❑Y ®N SYSTEM
❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s l 6 1, COM VEH ❑ El 1 0
~ Des Plaines I L 6001$ 0 1 0 FIRST CONTACT 7 O7 .; --5 *II Yes.See Sidebar U1 0
Z 1H805FF IL 2026
TELEPHONE
IL D 1 FTYR3XM6GKB03229 Progressive ❑Y ign4 U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same 993311115 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 KCv 0 DV
!1 9 6 9 Chevrolet Silverado 2012 00-NONE ,1_' 12 0 DUE TO CRASH ❑ ! l 2 x
0 13-UNDER CARRIAGE 10 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 1l, 4 COM VEH ❑ ® U1 CO
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FIRST CONTACT 1 Y , _5 •(ryes,See Sidebar
ELGINREAR
IL Other 1 GCRKSE77CZ269311 Geico ❑Y 123 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 6198423029 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER ut =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(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 ® 11 5 11 ,11 /2025 07 12 ®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
Eri 2 ❑ 04 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ID PM '
o N ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
t 2 ❑ 45
ARREST NAMEAM
x- 7 / / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE
2 2 3 0 ❑AM Workers present? ❑Y 45 TIME
562-Hernandez. Myra - r 1 ❑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
I I ADDITIONAL UNITS FORMS.
r ----r••--, , Mot_7b Scale_ J I N : A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' A INDICATE NORTH combination)or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
' """'""' 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O
,iil - } } I. transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
' I.
4. Is used or designated to transport between 9 and 15 passengers,includingC}--- ----; - } } } g po the driver,
for direct compensation(example:large van used for specific purpose):or O
L L____a____.: J I ` ew•rma _ t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •u
placarding(example:placards will be displayed on the vehicle). ,Zmt
.-. _. - - -- —I
CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --4. - USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
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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
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE