HomeMy WebLinkAbout2025-00079704 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 111111 it ll 1111 101111110fll 1111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004079790'
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00079704 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'l
RANDALL RD Elgin11:52
® ❑ RELATED ❑Y ®N 12 16 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ID PM FLOW CONDITION M0 !MI N E S W HO S St COUNTY PROPERTY ❑Y ® N DOORING ❑V #OF MOTOR 0 SLOW 1 (n
pp Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
(g)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 7 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 2 rn
F 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, ii_6 I, 4 COM VEH ❑ EJ 1 O
F. FIRST CONTACT 1 7 ;—_;__5 *Irves.See Sidebar
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V Z Sycamore IL 60178 0 1 0 AZ29158 IL 2026
TELEPHONE
IL D 0 1 FM H K8F82BGA73255 State Farm ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0657492-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
N DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 row N❑ V 0 DV
/1 9 8 Volkswagen Beetle 2018 00-NONE 11"j t2..-_, DUETO CRASH ❑ 2 x
o yr 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C
II
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8i 6 ....4 COM VEH ❑ ® u1 CO
I— FIRST CONTACT 5 7A-�-"05 •If Yes.See Sidebar C
E LG I NZ IL 60123 0 1 0 SYC654 IL 2026 REAR 0 Si)
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IL D 0 3VWFD7AT7JM710055 Pekin ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 005157831 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 03 / F 2 4 0 1 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
N 1 El 11 1 12/16 /2025 11 52 ®❑PM in a Work Zone? NJ N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0
1
2 0 28 03 / / ❑PM 0 Construction *
Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
o1 ® 11 1 ARREST NAME Carmona,Alexsandra 11-601 W1540-397 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
El AM
r 2 0 ARREST NAME 12/16 /2025 12 40 0 PM 0 Unknown work zone type U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 45
1540-Allah. Muhammad 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
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1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
i- }---.r----; I } combination):or —I
i INDICATE NORTH p1
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
V >� _ _ } (example:shuttle or charter bus):or
—~ '~ 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
des pa g pe by i
} } 1- transporting employees In the course of their employment(example:employee
— ~~ transporter-usually a van type vehicle or passenger car):or c0
HoppeR L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} for direct compensation(example:large van used for specificpurpose):or [he driver,
A Pe ( P 9 Pe or
L L____a____. I t i. i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
N placarding(example:placards will be displayed on the vehicle). ,Zmt
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rbrmswro CARRIER NAME —I
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ADDRESS
T.
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�_ CITY/STATE/ZIP 0
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- i. 4. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
---'--4. USDOT NO. ILCC NO. m
XI
Source of above z
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Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
XI
Did HAZMAT spit 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 M
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Black
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE