HomeMy WebLinkAbout2025-00081306 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110 II II IIIIII I III III IIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO04082586
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00081306 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
® ❑ RELATED PRIVATE ❑Y ®N 12 26 2025 ❑AM ❑YES ®NO U1 -<
N RANDALL RD Elgin mo /day/yr 03:32 ®PM FLOW CONDITION m
05 COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
® FT/0 N E OS W ALFT Ln WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑NV., ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
0 2 /
yr 13-UNDER CARRIAGE } FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O " 2 DISTRACTED 0 !� U2 04 r<n
F 2 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 THER
99-UNKNOWN O9 16-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 I, 4 COM VEH 0 0 1 0
f. FIRST CONTACT 11 7 ;—_(__5 *II sees.See Sidebar U1
Z ALGONQUIN IL 60102 0 1 0 CK33792 IL 2026 REAR
TELEPHONE
IL D 2LMPJ8LR2HBL38739 STATE FARM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 1-1
99 9 Same 1812946-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 73
x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
yr to' 12 ( 2 FIRE ❑ ® U2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPQ
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN O OistracI n value 9 Ut 9
POINT OF 6-.;,•
1,:,_4 COM VEH D ® IN
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT 6
FIRST CONTACT 3 7_.'_,�_5 •)ryes.See Sidebar
1= WOODSTOCKZ IL 60098 0 1 0 BZ26952 IL 2026 I 9
IL D 2A4RR5DG5BR613123 FIRST CHICAGO ❑Y (EN RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same I LV1267567-00 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (WI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 05 /
:A
/ / UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 El 11 1 12,26 /2025 03 32 ®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)
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2 ❑ 20 99 / / ❑PM ❑Construction *
1
Z3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME IDAM ❑Maintenance U2 5
a PETERSON.JANET. L. 11-709-A 1506-477 / / PM '
-, ARREST NAME ❑
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
50
t 2 ARREST NAME AM
T El / / ❑❑PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
1506-Nunez. Maria 901 269-Mendiola 11 , 3/ /026 09 00 ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -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
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. 1 <--_.... J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..i.____� l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ 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
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
Blue Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE