HomeMy WebLinkAbout2025-00044105 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0038-83212
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q 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)
0 AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00044105 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
RT20 RELATED ®Y 0 N 07 08 2025 05:16 12,— ❑YES ®No U1 -<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W SHALES PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 --I
IgI AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 5 /
yr
13-UNDERCARRIAGE fat 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY4 ❑Y ❑SNE®UNK VEH. 9 AT CRAS IN H 9 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 a �i 4 COM VEH 0 Ea 1 0
H 1= Berwyn I L 60402 0 1 0 FIRST CONTACT 1 7 . __5 *II Yes.See Sidebar U1
Z rwyFG 12069 I L 2026 Isui
TELEPHONE
IL D 1 FMJU1J50BEF22069 Progressive ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same 971562054 2 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
'1 9 yr1 Lexus ES350 2017 oo-NONE ,�_' 12 _, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 1a 1 E FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 016.70P 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I ,_4 COM VEH 0 im Ut CO
FIRST CONTACT 9 7 _s ••If Yes.See Sidebar C
Barrington 60010 0 1 0 ZV72991 IL 2026 REAR
0 Si)
IL D 58ABK1 GGXHUO38730 USAA ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same CIC0135554037101 BAc $
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)((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
N 1 ® 11 1 07(08 (2025 05 16 ®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 3 n
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2 ❑ 20 2 / / 0 PM ❑Construction *
4
R 3 0 $I CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
oER 11 1 ARREST NAME Sepulveda. Miguel.A. 11-709-A 1560000032 / ! ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
t 2 ElARREST NAME 07(08 12025 06 03 ®PM ElUnknown work zone type U1 55
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 55
1560-Jones. Bennett 401 08 ,05(2025 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
I
ADDITIONAL UNITS FORMS.
Rote?20
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; I _ 1. Hasor more thanpounds(example:truckortruckrtratler 1. Hasaweight rating10,000 -I
INDICATE NORTH combination): p0
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
0
r r (example:shuttle or charter bus):or X
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
`\ I. } } transporting employee In the course of their employment(example:employee X
__ -_ \ - transporter-usually a van type vehicle or passenger car):or w
\1 I uua 4. Is used or designated to transport between 9 and 15 C
} } } g po passengers,including the driver, to
for direct compensation(example:large van used for specific purpose):or O
L L_ ___; i=i L 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). XI/ / 2#
CARRIER NAME Z
4, I
ADDRESS
Z—). 1 12 i. CITY/STATE/ZIP 0
I _ MOTOR CARR.ID Interstate Intrastate
I I T I Not in Comm./Govt. Not in Comm./Other
I •
Not To scale 1 _ i. ;
o
,____Y____ USDOT NO. ILCC NO. m
I XI
Source of above z
. own tank)? 0 Yes 0 No 0 UnknownT.
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 VIM 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 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Gray
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE