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HomeMy WebLinkAbout2025-00075247 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI U� I� II If 1HHu1HH 111110DD DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X0040140655 u, 8 U2 1 1 1 U1 8 U2 U, 1 1_12 U, 1 U2 1 6 U1 18 U2 *P 0119* 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) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00075247 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 23 2025 ®AM ❑YES ®NO U1 -< RT20 WB Elgin mo /day/yr 07:32 ❑PM FLOW CONDITION m • 010O!MI N E S © North Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl) Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) FOR DAMAGED AREA(S) mom TOWED U1 0 Sundara.T ler 1 1 / yr 13-UNDER CARRIAGE 9 .!. 2 FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m M 2 4 is-OTHER ❑Y ®N SYSTEM ❑UNK VEH. O AT CRASHD O 99-UNKNOWN 016 3 `Distraction Value 7 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D;i�a F.4 COM VEH 0 1?� 1 O ~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 O 7 ; _-5 *If Yes.See Sidebar Ut Z P569046 IL 2026 E TELEPHONE IL D 0 19XFB2F85CE036405 American Family Ins ❑v ®N U2 m 2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Sundara.Arokha. P. 410988776618 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 73 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 Kcv 0 DV yr 12 - C o 13-UNDER CARRIAGE 10.i :., 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR n ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:=5 C•IO e1sVEH See •Sidebar❑ 0 C CO F` pEA,- C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 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❑YD❑N NDER U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 0 1 2 Elgin "Merge"traffic sign 11 ,23 /2025 07 33 ®❑pM AM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ;, 2 ® 43 2 150 DEXTER CT ELGIN IL 60120 20 17 ! ! ❑PM ❑Construction * Z3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 ou 1 ❑ ARREST NAME Sundara.Tyler 11-709-A 495000462 r / El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility t 2 0 ARREST NAME ! / ❑❑pM ElUnknown work zone type U1 50 n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 495-Sjodir.Jacob 901 12 ! 16 l2025 01 30 ®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 truck trailer -< ` ` -'- -' r INDICATE NORTH combination):or —I '• ,` ,`\ 0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ,\ ,``, `, } (example:shuttle or charter bus):or 0 • •\ •\``, ,`\`,` 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O ` 1 \ - } } } transporting employees in the course of their employment(example:employee X � •'‘, k,, transporter-usually a van type vehicle or passenger car):or w -----}----; • �,`�k, ,��, } } } •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 •L L____a____� �`\ ,��; 1 1 1 1 • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m .` ,,�� ,�� placarding(example:placards will be displayed on the vehicle). ;p • \\, \ , D • `� ,\�� \`, CARRIER NAME Z ` \,V` 1 _ ADDRESS 0 •` A.A._ \`\, ,, i. i. i. i. CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -Y- -'4 - USDOT NO. ILCC NO. m XI Source of above z . • m 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE