HomeMy WebLinkAbout2025-00058060 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II IIIIII 0110010111111111llIIl
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV XO039458O2`
u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 u, 2 u2 1 4 15 U1 11 U2 1 *P0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2O25I 2025-00058060 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
MAROON DR Elgin 07:55
® ❑ RELATED ®Y 0 N 09 03 2025 ❑AM ❑YES ®No U1 '<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W SHALES PKWY COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 2 tq
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 Peon. 0 EWES 0 Nuv 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
FOR DAMAGED AREA(S) FROPtf TOWED U1 O
NAME(LAST,FIRST,M) SHEPHERD.SAM IYAH. M. mo /
13-UNDER CARRIAGE 10 i ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 99 171
F 2 5 ❑Y ®Nn 15-OTHER
SYSTEM
❑UNK VEH. AT CRASHO 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH ❑ j$J 1 O
H 1- LAKE I N THE HILLS I L 60156 B 1 0 FIRST CONTACT 12 r: _5 *If Yes.See Sidebar U1
Z4010083 IL 2026
TELEPHONE
IL D 0 3FADP4EJOBM240113 AARP ❑Y ®N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 SHEPHERD.JEWEL. M. 55PHB890376 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NI/v 0 Ncv ❑DV
/1 9 y3r 0 Dodge Ram 3500(pickup) 2006 00-NONE 10 t2 ( 2 FIRE DUE ocRASH ® U2 2 C
o 13-UNDER CARRIAGE XI
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 I1,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 5 7 —_,SOS •(ryes,See SidebarC
ELGIN IL 60120 0 1 0 518990D IL 2025 I 0
IL D 0 3D5MX48CX6G119227 STATE FARM ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Garrido-Arevalo. Melvin.O. 3446383-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
u1 =
(UNIT) (SEAT) (DOB' (SEXI {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 6 07 /
' D
/ / 4 O
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
N 1 ® 11 1 91 //2 /25 07 56 ®AM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
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2 0 2 99 / / 0 PM• ❑Construction
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME SHEPHERD.SAMIYAH. M. 11-901-A 1559000054 / / ID PM SLMT
® 11 1 0 CITATIONS ISSUED ❑PENDING Utility
o u 1 SECTION CITATION NO. ROAD CLEARANCE TIME • 0
T 2 El ARREST NAME 9/ //2 /25 08 24 ®PM El Unknown work zone type U1 El AM 25
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1559-Dave los.Yoana 302 10 /21 /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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A .13. 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
; f Maroon?0r.1 transporter-usually a van type vehicle or passenger car):or w'' TOa01r't 4. Is used ordesi natedtotrans rtbetween9and 15 C
} } } g po passengers,including the driver, (/)
for direct compensation(example:large van used for specific purpose):or
L l. l. I 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
T' I placarding(example:placards will be displayed on the vehicle). ,Zmt
I —I
LShataa?Pkwyr_ CARRIER NAME Z
i ADDRESS 0
V)
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
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 E
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' m
TRAILER 1 0 0 0 Z
1-1
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Green White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Arties/Impound Lot Garage 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