HomeMy WebLinkAbout2025-00031078 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
M011011000010111111111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003623699*
u, 1 U21 1 1 1 U1 2 U2 1 u, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 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/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00031078 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 05 16 2025 ®AM ❑YES ®NO U1 -<
S RANDALL RD Elgin mo /day/yr 11.56 ❑PM FLOW CONDITION M
•
15(� COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR ❑SLOW 1 (/)® �C.7/MI N E O W Weld St 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
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGED AREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Siete. Michael.A. mo / /1 9 9 2 Dodge Avenger 201 4 00-NONE 11 O _, DUE TO CRASH ® ❑
13-UNDER CARRIAGE 1a i , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED THER ❑ ❑ U2 4 M
M 2 SYTM 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 Ea 1 0
~ SOUTH ELGIN I L 60177 0 1 0 FIRST CONTACT 12 7 ;1 _5 *IIYes.See Sidebar U1
Z Z123887 IL 2024 Isui
TELEPHONE
IL D 0 1 C3CDZAB1 EN 150980 State Farm ❑Y IlN U2 1 -
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 1442192-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 i v ❑Dv
/1 9 7 4 Infiniti QX6O 2014 00-NONE 1t"i 12'-_, DUETO CRASH 0 2
o _y Yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c ®
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI 6 �,_4 COM VEH ❑ ® ut CO
FIRST CONTACT 6 Y__{_O ._5 •iryes.See Sidebar
11". ELGIN IL 60124 0 1 0 Z207347 IL 2025 izEAu
M
IL D 0 5N1CLOMMOEC529807 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 1992892-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 09 / F 14 4 0 1 0
m
/ / #OCCS D
P3
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 05/16 /2025 11 56 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 ❑ 28 99 05,16 /2025 11 56 ❑PM El Construction
R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Siete. Michael.A. 11-601-Ax 1548-000045 05,16/2025 12 00 ®PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
T 2 El ARREST NAME 05/16 /2025 01 29 ®PM 0 Unknown work zone type U1 0 AM 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
1548-Crandall. Matthew 702 06 ,03/2025 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••--, , I i=, - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i n-ca 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
- }-_-_r__--; combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
® " " " " • I _ (example:shuttle or charter bus):or
Not Tb Busk J
L A I C.
v _, ? 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L i 4. Is used or designated to transport between 9 and 15 se including (-----}----; ® - } } } g po passengers,indudi the driver,
for direct compensation(example:large van used for specific purpose):or O
L t 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). ,Zmt
—1
" n- n t CARRIER NAME Z
ADDRESS 0
D
«rwr rc CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- ----1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. If Yes,Name on placard O
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BYlT6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE