HomeMy WebLinkAbout2025-00075658 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III III 11 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004045476
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00075658 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 11 25 2025 ®AM ❑YES ®NO U1 -<
FOOTHILL RD Elgin09:53
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FTlMI N E S W BROOKSIDE DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
FOR DAMAGEDAREA(S) FRONT TOWED EN
U1 0Harbin.Tara. L. 1 1 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 99 m
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM 161 H 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,;il B 4 COM VEH 0 Ea 1 0
H 1- HOFFMAN ESTATES IL 60192 0 1 0 FIRST CONTACT 12 T : _s uYes.seesiaabar u1
Z EX55422 IL 2026 E
TELEPHONE
IL D 0 1 GKKVPKD1 FJ229992 American Freedom Ins Co ❑Y ®N U2 31 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Same 12248216200 2 I—
t HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER eV
Refused ❑Y ® N 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑r uv 0 NCv ❑DV
'1 9 8 7 Toyota Prius 2010' 00-NONE ,�_' 12 _, DUE TO CRASH ❑ 2
0 Yr 13-UNDER CARRIAGE fir! 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistracIonValue 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ) S i!,_ COM VEH ❑ ® Ut CO
FIRST CONTACT 8 O7 _, _s •(ryes,See Sidebar C
NAPERVILLE IL 60540 0 1 0 EW29360 IL 2026 I 0 Si)
IL D 0 JTDKN3DU8A0049540 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3433877SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 ,25 /2025 09 54 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 28 99 + / ❑PM ❑Construction *
Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Harbin.Tara. L. 11-601-Ax 495000465 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
t 2 ❑ ARREST NAME AM/ / ❑❑PM ❑Unknown work zone type U1 4O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 40
495-Sjodir.Jacob 702 12 / 16/2025 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 truckrtrailer -<
i- }---.r----; ( INDICATE NORTH combination):or -I
p1
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 O
} } } transporting employees In the course of their employment(example:employee X
L L.___a____� \ transporter sed or des usually
nated to eh betweeicle or n9andr 15r) ssen rs,indudirg[he driver. C
\ 0 } } for direct compensation(example:transportlarge van used for specific purpose):or 0
L i.____a____. \ t i i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
pMcarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESS 0
T.
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scale J O
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes ❑ No 0 Unknown 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
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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 White
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE