HomeMy WebLinkAbout2025-00073666 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 10110 ll 1111 Ifllfl Ill fl 00 00 0
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004033t018
u, 1 U2 3 4 1 U, 2 U2 u, 1 U2 U, 1 U2 1 6 U1 1 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00073666 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N RANDALL RD El In05:42
® ❑ RELATED ®Y ❑N 11 15 2025 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W W H I G H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 -I
igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 1 /
Chevrolet Impala 2011 00-NONE 0: Oil DUE TOCRASH ® ❑
13-UNDER CARRIAGE ) : 2 FIRE 0 ® C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
M 2 4 ❑Y ®SNEM❑ is-OTHER
UNK VEH. O AT CRASHIND O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI B 4 COM VEH 0 Ea 1 00
F. FIRST CONTACT 12 7 _5 *Irves.See Sidebar U1
Z Wheaton IL 60187 0 1 0 CX29003 IL 2006 ,
TELEPHONE
IL D 0 2G1 WB5EK1 B1282273 AUT700868474 0 Y ® 4 U2 r
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Mahr.Joseph.A. Auto Club Insurance 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
rg-
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 NCV 0 DV
yr 12 _ X
.0 13-UNDER CARRIAGE I c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 El ❑ SPDR 0
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 -4 *Oistracton Value 0 -
-
EH
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y •
:-9 •CIO e1sVSee Sidebar❑ 0 U1C
CO
F` pEAR='+` C
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 4 City Of Elgin Road Curb 11 ,15 /2025 05 42 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 50
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v t 2 0 150 DEXTER CT ELGIN IL 60120 28 18 ! ! ❑PM 0 Construction >F
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME / / ❑PM '
o U 1 0 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o N 0
AM u, 45
t 2 0 ARREST NAME 11!15 /2025 05 42 In PM 0 Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 1560-Jones. Bennett 901 360-Yucaitis , , ❑❑PM Workers present? ®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••--, , I ` 1 ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
y l r INDICATE NORTH 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
combination):or -<
c ` --I -' l 1
—I
1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ i.. -:. \ \ _ } (example:shuttle or charter bus):or
11 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- I- -A- --i `
- } } } transporting employees in the course of their employment(example:employee
rter-
enger
or CO
C
i. <.__-a__._' 1 N - 42lsuosedordesgnatedto tranlly a van type sport betweeicle or n9a d15rpassen rs,includingthedriver,
} } } for direct compensation(example:large van used for specific purpose):or
L l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
__41
placarding(example:placards will be displayed on the vehicle). XI
s — — — D
CARRIER NAME Z
— — Z
ADDRESS
D
1 j C)
� Not To scale CITY/STATE/ZIP 0
k l - MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I l 1 1 ❑ Not in Comm./Govt. Not inComm./Other
1 1
t 1 USDOT NO. ILCC NO. m
XI
Source of above z
.
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO T6 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE