HomeMy WebLinkAbout2025-00003730 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
I01101100 0 I I II 1 110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a699381
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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 ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00003730 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
® ❑ RELATED ❑Y ®N 01 17 2025 ❑AM ❑YES ®
PRIVATE NO U1
RT20 WB Elgin mo /day/yr 05:45 ®PM FLOW CONDITION m
1 O(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 co
® C.7!MI N E S ® Grace St WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FIX)Ni TOWED U1 Q
Sanchez.Ser Io 0 4 /
yr 13-UNDER CARRIAGE ) 2 , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m
M 2 SY n 15-OTHER
8 ❑Y ®SNE M DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI S 4 COM VEH 0 j$J 1 0
I .
ELGIN I N I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *If Yes.See Sidebar U1
Z 21936Z-B IL 2022
TELEPHONE
IL A 7 1 FTRWO8W31 KA21705 Main Street America ❑Y Igl N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same A21292927 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Refused ❑Y ElN 2 0
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 MAV 0 NCv 0 DV CIRCLE NUMBER(S) U1
1 9 8 7 Jeep(after 196�)npass 2021 00-NONE ,t-' 12-- DUE DUE TO CRASH rg ❑ 2 73
13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
Ti;
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 g
s 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 l:' COM VEH El ® U1 CO
FIRST CONTACT 6 7- Q,_-5 •If Yes.See Sidebar
— Dekalb IL 60115 B 1 0 CW23010 IL 2025 REAR 0 Si)
IL D 0 3C4NJCBBXMT570986 American Family ®Y ❑N RDEF 7:l
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 41090-05251-53 SAC 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 (71 )025 05 46 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 11 1 28 18
( ( 0 PM• 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Sanchez.Sergio 11-601-Ax 499000758 / ! El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
r 2 El NAMEAM
c- 7 ( / ❑❑PM 0 Unknown work zone type 45
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
499-Dirck.Cameron 401 334-Fries ( ( ❑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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
i` i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
p - } (example:shuttle or charter bus):or
T,NOt To Scale
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L I- --I--
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or co
L 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 t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
Rym placarding(example:placards will be displayed on the vehicle). XI
_ ,\ _ _ _ _ _ _ _ CARRIER NAME
� g—•\uNir Nrrti - __ ADDRESS 'O
V)
illI i. CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
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
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
Red Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE