HomeMy WebLinkAbout2025-00042784 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011000 000 0100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003878105
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ 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 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00042784 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
RANDALL RD Elgin 01:53
® ❑ RELATED ❑Y ®N 07 03 2025 ❑AM YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FTlMI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NIAV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 8 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<n
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH ❑ Ea 1 0
~ ELGIN IL 60124 0 1 0 FIRST CONTACT 12 7 ;1 __5 *IIYes,SeeSidebar Ut
ZTAKO-DD IL 2025
TELEPHONE
IL D 19XFB2F51 CE014925 Progressive ❑Y ®N U2 31 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Sanchez. Emmanuel 998589126 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
N DRIVER ❑ PARKED ❑ORIVERLESS 0 PEO ❑PEDAL 0 EWES ❑!My 0 NOV ❑DV
2 0 0 6 Ford Escape 2013 00-NONE 'o,1 t2 - i DUE FIRE ID
CRASH D ® U2 2 C
o 13-UNDER CARRIAGE
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S --4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 6 O7 ,�=Q,OS C.
If Yes,See Sidebar C
ELGIN IL 60124 0 1 0 Q949359 IL 2025 FIRST
0 N
M
IL D 0 1 FMCU9J95DUA09175 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Solomon.Christophe.C. 2286716-SFP-13 BAC 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)
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 07!03 l2025 01 53 ®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
o"
2 0 28 99 ! ! 0 PM. ❑Construction *
Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Sanchez. Nolan. E. 11-601-Ax 1547000108 ! ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
45
t 2 0 ARREST NAME AM
7 ! r ❑❑PM 0 Unknown work zone type U1
%
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1547-Steele.Justin 702 08 !05 l2025 09 00 ❑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
�____r____; I Iir
_ combination):Haseightratingmorethan10,000pounds(example:truckortruckrtrailer -<
1.
INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O
} } } transporting employees In the course�of their empbym�ent(example:employee � �transporter-usually a van type vehicle or passenger car):or w/ ^ 4. Is used ordesi natedtotrans rtbetween9and15 ge ng N} for direct com nation exam I lar a van used for s �cifice ur o ):or [he driver,Pe ( P 9 Pe P Pose):or/ / t l. i 1 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'Dr m
placarding(example:placards will be displayed on the vehicle). X/CARRIER NAME Z
ADDRESS 0
Not To Scale I T.
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. -- - - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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 M
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
_Other/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE