HomeMy WebLinkAbout2025-00022928 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00022928 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
LILLIAN ST Elgin 08:23
® ❑ RELATED ®Y 0 N 04 11 2025 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT N E S W S MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0(Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 0 0
FOR DAMAGEDAREA(S) FRO T TOWED U1 O
Sandoval.Wilfrido. R. 0 9 /
yr 13-UNDER CARRIAGE t ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 0 rn
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 ,6•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 �i 4 COM VEH 0 j$J 1 0
ELGIN I L 60124 0 1 0 FIRST CONTACT 11 7_;1 __5 *II Yes.See Sidebar U1
ZZELDA21 IL 2025 REAR
TELEPHONE
IL D 0 WA1 EAAFY6R2021646 State Farm ❑Y Il N U2 13 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0228166-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
Eg DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 Ncv 0 Dv
/1 9 yr 4 Mazda CX5 2017 00-NONE till 12 :-y FIRED CRASH ® U2 2 C
0 13-UNDER CARRIAGE IIIEl
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP®* X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN Oistracti n Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 1( 4 COM VEH D ® U1 CO
FIRST CONTACT 3 7-.'_, _5 *If Yes,See Sidebar
Z SOUTH ELGIN IL 60177 0 1 0 EX36431 IL 2025 RE 0 N
M
IL D 0 JM3KFBBL4H0160606 Direct Auto ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same PAIL001241757 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 6 09 / M 2 4 0 1 0
m
/ / #OCCS D
Xl
/ / U1 1 D
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 4 04,11 /2025 08 23 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 2 n
T
o"
2 ❑ 2 07 / / 0 PM ❑Construction
R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Sandoval.Wilfrid°. R. 11-306 W1542-000210 / / ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
El AM
T 2 El ARREST NAME 04/11 /2025 08 42 ®PM El Unknown work zone type U1 35
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1542-Chase. Ethan 701 - / / ❑❑pM Workers present? ®N U2 30
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
I I • 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }---_r__--; I I ` INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
} I I \ _ } (example:shuttle or charter bus):or 0
nne?fensrre 3. Is designed tocarry15fewer passengers and operated bycontractcarrier` or sf a a ne O
es
}.___A.._.J ® -- . } } } transportingemployees in the course of their employment(example:employee X
J I transportr-usually a van type vehicle or passenger car):or CO
L L.___a.. I. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } • for direct compensation(example:large van used for specificpurpose):or [he driver,
• o Pe ( P 9 Pe or O
L L____a.....I C:N�� t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
Unit 2
CARRIER NAME Z
or I1 1.1114nntrwt O
I I ADDRESS
2.7 pgn�gpb I I CITY/STATE/ZIP g
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
�""Y""1 USDOT NO. ILCC NO. C
m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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
71
IDOT PERMIT NO. WIDELOAD'; 0 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Black
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