Loading...
HomeMy WebLinkAbout2025-00079312 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 1111 100 II 0E11 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X�068658 u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-S1,500 ®ON SCENE 7 VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ® B Injury and/or Tow Due To Crash YR 202512025-00079312 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1 1100 S RANDALL RD Elgin08:47 ® ❑ RELATED ❑Y ®N 12 14 2025 ®AM ❑YES ®NO U1 -< _ PRIVATE mo /day!yr ❑PM FLOW CONDITION m COUNTY PROPERTY ®Y 0 N DOORING ❑y #OF MOTOR ®SLOW 15 u) ❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O g 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 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Naraharasetty. 0 4 / yr 13-UNDER CARRIAGE ©,I O,.-Z FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m M 2 SY4 ❑Y ONM❑UNK VEH. O AT CRASH IN 0 is-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a Ii COM VEH ❑ 0 1 0 ELG I N I L 60124 0 1 FIRST CONTACT 11 7_: __5 *irsees.See Sidebar U1 Z CT16894 IL 2025 REAR TELEPHONE IL D 0 4T1 BE46K78U248580 Progressive ❑v igi N U2 31 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 979 379 734 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 rg- g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑DV !1 9 5 7 Ford Edge 2012 00-NONE 0. Q1-_, DUE TO CRASH ❑ 2 xj 0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 U2 C c F 2 4 SYSTEM IN 9 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 POINT OF U1 0 i1 CON CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 i 4 COM VEH ❑ ® FIRST CONTACT 11 8 7 L _,__5 •If Yes.See SidebarC — Hoffman Estates IL 60192 0 1 STORM57 IL 2025 REAR 0 Z IL D 0 2FMDK3KC5CBA36494 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 911 250 795 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 5 12,14 ,2025 08 47 ®❑AM 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 C) 453. 2 0 2 23 12,14 (2025 08 48 PM ❑ • ❑Construction * Z 3 ❑ O CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ®AM ❑Maintenance U2 -a ARREST NAME 12(14,2025 08 51 ❑pM 1 2111 1 0 CITATIONS ISSUED SECTION CITATION NO PENDING SLMT , N ® . ROAD CLEARANCE TIME o El Utility y AM u, 05 F 2 El ARREST NAME 12(14 (2025 09 05 [0 PM ❑Unknown work zone type n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 05 260-Sheehan.Joseph 801 , ! ❑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 } }----'-----; ® Not To Scale - !' INDICATE ARROWENORTH combination):or p3 2 Is used or designed to transport more than 15 passengers including the driver —I 1. � T 1 } (example:shuttle or charter bus):or 0 a.nr,cwe 3. Is designed to carry15 or fewer0 g passengers and operated by a contract carrier 10 } } } transporting employees In the course of their employment(example:employee X __ ...I. Tj 1 I - transporter-usually a van type vehicle or passenger car):or co 1 4. Is used or designated to transport between 9 and 15 passengers,including C} } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O L i.____a____.i - - .•, - - _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m 0 rg CARRIER NAME —I Ifti Z - I 1 __ ADDRESS 0 T. rA w".°" I CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate El Intrastate r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __.; - USDOT NO. ILCC NO. m XI Source of above z xi 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 ❑ 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Bluew u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE