HomeMy WebLinkAbout2025-00046136 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 0110110011 011110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03894778
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00046136 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 07 16 2025 ❑AM ❑YES ®NO U1 -<
MULBERRY LN Elgin11:30
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
70 /MI N E S W South Lyle Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 Cl)
® ® y Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
lg DRIVER p PARKED El DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Saenz.Saul 1 0 /
yr 13-UNDER CARRIAGE 101 !�. 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M I 2 SY4 ❑Y ONM❑UNK VEH. 0 AT CRASH IN 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL S i COM VEH 0 j$J 1 0
~ SOUTH ELGIN N I L 60177 0 1 FIRST CONTACT 1 7_; __5 *lI Ves.See Sidebar U1
Z EV96019 IL 2025 E
TELEPHONE
IL D WAU FFAFLXFN003318 Allstate ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 811287059 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr Honda Civic 2015 00-NONE 11_` t2 "_1 DUE TO CRASH ❑ ® 1 ,')/
Ti 13-UNDERCARRIAGE o I 2 FIRE ❑ ® U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 0 ® SPDR n
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 U1 0 -
POINT OF 8 ) 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S l!._ COM VEH ❑ ® CO
F,,, FIRST CONTACT 9 7 , _5 C.
If Yes,See Sidebar
BSY8686 TN 2025 REAR 0Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
19XFB2F53FE106056 American Alliance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Santiago Marquez.Yecmanuel.A. 105438000 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 07,16 l2025 11 30 ®PM in a Work Zone? ®N DIRP co
I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 04 28 1 1 0 PM 0 Construction *
1
Z3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
o1 ® 11 1 ARREST NAME Saenz.Saul 11-601-Ax W1513000783 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
t 2 El ARREST NAME 07 r 16 12025 11 30 0 PM 0 Unknown work zone type U1 3O
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1513-Mann. Nathaniel sot , ❑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
r f combination):or more than pound (example:truck or truckrtraller 1. Has a weight rating10 000 5 i -<
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
s?L*wA. - (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or o
L i t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
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U. , . , . CARRIER NAME Z
ADDRESS 'C)
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i. i. i. i. 4. C)
CITY/STATE/ZIP
_ i. MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scale 0 Not in Comm./Govt. 0 Not in Comm./Other 00
‘I. - --1 - USDOT NO. ILCC NO. C
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XI
Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE