HomeMy WebLinkAbout2025-00000783 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00000783 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y ❑N 01 04 2025 ❑AM ❑YES ®NO U1
S RANDALL RD Elgin12:04
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W WELD RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FROhrr TOWED U1 Q
NAME(LAST,FIRST,M) PELAGIC). MARCO. F. mo General MotorSiQoq 2023 00-NONE ,1,. O i_, DUE TOCRASH ❑
EN
13-UNDER CARRIAGE 10 : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M I 2 4 ❑Y ®SNEM DUNK VEH. AT CRASHD 99-UNKNOWN 9 76•TOP 3 *Distraction Value 5 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1 B 4 COM VEH 0 1� 1 0
F. FIRST CONTACT 12 7 _5 *If Yes.See Sidebar U1
Z SAINT CHARLES IL 60175 0 1 0 3239865B IL 2025 ,
TELEPHONE
IL D 0 1GTVUCE8OPZ286464 SELECTIVE-A.M INSURANCE ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
PELAGIO AND SONS S2417510 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 N v 0 DV
!1 9 9 5 Mercedes-Bennprinter 2021 00-NONE +i_"i 12--_, DUE TO CRASH ❑ C 2 73
13-UNDER CARRIAGE 10;1 2 FIRE ❑ ® U2 C
Ti;
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
POINT OF s iI ' 4 COM VEH ❑ ® Ut co
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 5 �'_
FIRST CONTACT 6 Y__{_O ._5 •IfYes,See Sidebar
Z GILBERTS IL 60136 C 1 0 157143C IL 2025 REAR 0
IL D 0 W1Y40CHY2MT062643 AMERICAN FAMILY ❑Y 123 N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 410903441060 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
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 0 Y U2 Z
u 1 ® 11 1 11 r 12 j25 12 04 0 AM in a Work Zone? ®N DIRP co
1 r 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 ❑ 03 28 ) ! ❑PM ❑Construction *
Z3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
ARREST NAME
PELAGIC). MARCO. F. 11-710-C 456-417(w) / j ❑PM
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING Utilit SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME Ely
r 2 ❑ ARREST NAME 1) 1)2 125 12 04 ®PM 0 Unknown work zone type U1 0 AM
45
n 7 -
OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
456-Romalo.Carmine 801 334-Fries j / ❑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.
. 0
r -T.
•--, , I I ... . 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- `-- ''-- --' I I ) INDICATE NORTH combination)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
i_ .:.. -:. j I 11 L
_ (example:shuttle or charter bus):or C
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
— - I' l- . transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__._� �„� ' / 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, O
I for direct compensation(example:large van used for speific purose):or
' I I Not To Scale l. < 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
I '1
_ CARRIER NAME ADDRESS Z
'Z
D
rn
CITY/STATE/ZIP 0
0
I MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
USDOT NO. ILCC NO. m
I XI
Source of above 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 White
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