HomeMy WebLinkAbout2025-00002452 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 II 011000011
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY XO0 689628
u, 1 U21 3 3 1 U116 U2 1 U, 1 U2 1 U, 1 U2 1 5 11 u, 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED YR ZOZSI 2025-OOOOZ452 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 I
® ❑ RELATED ❑Y ®N 01 11 2025 ❑AM ❑YES ®
PRIVATE NO U1
S RANDALL RD Elgin mo /day/yr 05:43 ®PM FLOW CONDITION m
010 ®!MI N E 0 W WELD Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ElSLOW 1 cn
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n
FOR DAMAGEDAREA(S) FROf T�OUETOCRASH TOWED U1 Q
Sakolari.Andreios. R. 0 1 /
yr 13-UNDER CARRIAGE 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 6 m
1U
M 2 SYTM IN ENGAGE4 ❑Y ®S NE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il a �i 4 COM VEH 0 Ea 1 0
F• Elgin I L 60124 0 1 FIRST CONTACT 1 7 . -_5 *Irves.See Sidebar U1
Z 9 492852D IL 2025 Ismi
TELEPHONE
IL 7 1 FDWE3FNXMDC38965 Perkin Insurance ❑Y ISI N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Sakolari. Raman 006217483 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NW 0 e v ❑ CIRCLE NUMBER(S) U1
Dv
1 9$1 Chevrolet Equinox 2019 00-NONE 10' t2 (,-2 FIRE DUE D CRASH ® U2 2 C
oP. 13-UNDER CARRIAGE ID
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S .t. 4 C.OM VEH ❑ ® Ut CO
FIRST CONTACT 6 O7 ,�=Q:OS •If Yes.See Sidebar C
ELGIN IL 60123 B 1 DE77472 IL 2025 aRSi)0
IL D 0 3G NAXH EV4KS656336 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Elgin Fire 99 9 STROMAN.ODETTE.G. 1117545SFP13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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/ ,, U1 1 D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 01 !11 l2025 05 43 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 28 03 / / 0 PM ❑Construction *
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Sakolari,Andreios. R. 11-601 S1507000348 / ! El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 El ARREST NAME 01!1 1 l2025 06 30 0 PM El Unknown work zone type U1 5O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 50
1507-Ruiz.Alondra 801 02 ! 11 l2025 01 30 ®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 -<
i- }__-_r_-__; I I ( combination):or
INDICATE NORTH p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} lis I I _ (example:shuttle or charter bus):or n
Not lb Suers J r r r X
gtoal � hEersantl operated by a contract carrier O
✓ I I< �. _A.._.. webam transportingemployeesln thecourseott , hpoymen(exampe:empoyee transporter-usually a van type vehicle or passenger car):or w
L L.___a.._.� - - - - 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
- - - } } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( 9 Pe or
L __-a..... I _ i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
— _ placarding(example:placards will be displayed on the vehicle). XI
1 r CARRIER NAME
~^I i Z
ADDRESS
T.
CITY/STATE/ZIP 00
I 1' I _ i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
� "Y""1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 0 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. w
White Silver
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 ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE