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HomeMy WebLinkAbout2025-00079083 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III II IIIIII UHI II II II IIIII III II IIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004068577' u, 9 U21 3 4 1 U1 2 U2 1 U1 99 1_12 1 u,99 U2 1 4 11 u, 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ❑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 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00079083 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m S RANDALL RD Elgin08:58 ® ❑ RELATED ❑Y ®N 12 12 2025 ❑AM ❑YES ®NO U1 g PRIVATE mo /day/yr ®PM FLOW CONDITION m E050 !MI N E S W South Royal Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ® YKane HIT&RUN ®Y ❑ N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Unknown ! ! Unknown Unknown op-NONE ©, 12 , DUE TOCRASH ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ Ea U2 6 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN 2 s 4'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,Ii_S Ii,_ 1 I— 0 9 FIRST CONTACT 7_11 : COM VEH ❑ Ea _5 *IIYes.See&debar U1 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ Unknown ❑Y ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r RESPONDER0 0 W g DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES 0 NuV 0 KCV 0 DV !1 9 yf 9 Nissan Rogue 2015 00-NONE 11"j t2..-_, DUE TO CRASH ❑ 2 73 0 13-UNDER CARRIAGE 10'( 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S .I S --4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,�=Q)O5 •If Yes.See Sidebar C ELGIN IL 60124 0 1 0 EG82221 IL 2026aR Si)0 Z IL C 0 5N1AT2MV1FC853345 Mercury Insurance ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same I LAP0000002675 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 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 12,12 l2025 08 58 ®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 � 0 2 0 03 99 I ! ❑PM ❑Construction * Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 —a, ARREST NAME / / ID PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT ou SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y t 2 0 ARREST NAME 1 21 12 12025 08 58 ®PM El Unknown work zone type U1 0 AM 45 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 El AM Workers present? ❑Y 45 1500-Chew. Marie 907 269-Mendiola , ! ❑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••--, , ^N - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z III 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< ' }----r----; } combination):or —I INDICATE NORTH p1 Not To Scale I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or 0 X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X g transporter-usually a van type vehicle or passenger car):or w I. I 4. Is used or designated to transport between 9 and 15 passengers,including C }--- ----; a - } } } g po passen rs,includi the driver, • for direct compensation(example:large van used for specific purpose):or O L L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D It placarding(example:placards will be displayed on the vehicle). XI Z CARRIER NAME Z ADDRESS 0 T. w 4 J lr ` CITY/STATE/ZIPg MOTOR CARR.ID 0 Interstate 0 Intrastate r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rTt RayY7Bid , • , , ' X1 Source of above z . ❑ 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE