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HomeMy WebLinkAbout2025-00076525 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 1111 I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004053205 u, 1 u21 1 1 3 u, 4 U2 1 u, 1 1_12 1 u, 1 U2 1 1 14 u, 1 u2 1 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00076525 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ® ❑ RELATED ❑Y ®N 11 30 2025 IMAM ❑YES ®NO U1 N RANDALL RD Elgin08:36 g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill FT l MI N E S W WIN HAVEN DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 6 Cl) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EouES ❑NW ❑ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 1 0 / yr © Q 0 ® ❑ 13-UNDER CARRIAGE 10 I 2 FIRE 0 NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Nj U2 2 rn F 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP 3 `Detraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�B 4 COM VEH 0 j$J 4 0 F. FIRST CONTACT 12 7_:—__,__5 *lives.See Sidebar Ut V Z Crystal Lake IL 60014 0 1 0 1684544B IL 2026 REAR TELEPHONE IL D 0 1 GCEK19B25Z300460 All State ❑v ®N U2 I - in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 962164560 3 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEON. 0 EWES 0 IIUV 0 NcV 0 DV yr 2 0 13-UNDER CARRIAGE 10( Ic 2 FIRE ❑ ® U2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH D ® W FIRST CONTACT 12 7 .5 •If Yes.See Sidebar 60110 0 1 0 EC73650 WI 2026 IO CC/) IL D 0 1 FDWE3FS6GDC41842 West Bend ❑Y ISI N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X Winter Services Inc. c056530 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP u1 = (UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 11 !30 l2025 08 36 ®❑pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 0 28 99 ! ! 0 PM ❑Construction >F N 1 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 o1 ER 11 1 ARREST NAME Ewingo Ostergaard.Andrea. R. 11-601 W1531000205 / ! ❑PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 50 t 2 ARREST NAME AM 7 ! r ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 50 1531 Sch�mbach.Jack sot ! ! ❑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••--, , ID . A CMV is defined as any motor vehicle used to transport passengers or property and: Z ` 1 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - i- }-- -'-- --; _ r) Not To Sce/e _ [ I combination):or -I NDICATE NORTH iii BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ''^11°""'OR I _ (example:shuttle or charter bus):or I 'i 3. Is designed to car 15 or fewer passengers and operated by a contract carrier I O , � � I - } } } transporting employees in the course of their empbgeym�ent(example:employee X -----}----; - • } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15r r including the driver, for direct compensation(example:large van used for specific purose):or C < a l 1 _ } < < _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 1 ` D ` placarding(example:placards will be displayed on the vehicle). m l \c.44\7 CARRIER NAMEZ_ __ ADDRESS D w , CITY/STATE/ZIP g \\\ \ \ \ _ MOTOR CARR.ID 0 Interstate ElIntrastate 1 I r 1 \ \ ❑ Not in Comm./Govt. 0 Not in Comm./Other 0 USDOT NO. ILCC NO. C XI Source of above z ' . 0 Yes 0 No ❑ Unknown A 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 71 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 Black Yellow u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE DUE