HomeMy WebLinkAbout2025-00061254 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003966748
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00061254 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 -n
N RANDALL RD Elgin08:27
® ❑ RELATED ®Y ❑N 09 18 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W FOOTHILL RD COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Egl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FR 4T TOWED U1 Q
Melet.Sahin 1 1 / yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 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 $ iII s j} COM VEH ® ❑ 1 n
F. FIRST CONTACT 6 7__:I-Q,--5 *II Yes.See Sidebar U1 0
Z Woonsocket RI 02895 0 1 0 P1280284 IL "u
TELEPHONE
OH A 7 4V4NC9EH2SN66571 8 Acord 1 Assured Partners N ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 E&O Solutions Inc PC25091227 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
20 0
tg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv ❑DV
!1 9 8 3 Chevrolet Equinox 2017 00-NONE O Ql-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7� .5 •(ryes.See Sidebar
H ELGIN IL 60123 0 1 0 DR17037 IL 2026 RE 0 C
M
IL D 0 2G NALCEK6H1 59801 3 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 1 1 88003-SFP-1 3 BAG $
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)1(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 CD 11 1 91 ,81 l025 08 27 ®❑AM in a Work Zone? ®N DIRP co
I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 30 28 I ! ❑PM ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Melet.Sahin 11-1402-A W1542-000457 ! ! El PM SLMT
1 ® 11 1 0 CITATIONS ISSUED ❑PENDING Utility
o NSECTION CITATION NO. ROAD CLEARANCE TIME 0
t 2 ❑ ARREST NAME 91 181 1025 09 15 ®PM ❑Unknown work zone type 0 AM
U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1 Chafe. Ethan sot , r ❑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
01. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -
` ` ' ' _ 70 Scxk J r INDICATE NORTH combination):or -I
• \ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ \ \ - } (example:shuttle or charter bus):or 0
\ \ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
\ \ � i-} } transporting employees In the course of their employment(example:employee 73
i. .:. .}----; \1 \ - } •transporter. sed or des gnated to translly a van type port betweeicle or n 9 and 15 enger passengers,ssen rs,including the driver. C or CO
40 1 \ } } for direct compensation(example:large van used for specific purpose):or O
L L--_-a-....l ` „ - t i 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). ;p
: ;. CARRIER NAME Price Rite Transport LLC Z
s �''`' ' ADDRESS g SHAW RD D
f '. ro
t�t�r CITY/STATE/ZIP Conklin I NY 1 13748 M
`� ` \\\ `'^ - i. i. i. i. MOTOR CARR.ID El Interstate ❑ Intrastate
/ El Not in Comm./Govt. 0 Not in Comm./Other 00
--- "1 USDOT NO. 2531368 ILCC NO. C
m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash? A
0 Yes i No ❑ 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'7 ❑Yes ®No 2
TRAILER VIN 1 3H3V532K9SS133054 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ® ❑ 0 Z
TRAILER 2 0 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53' ft. 2 ft. w
Gray Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES 5
DUE TO ❑ DISABLING DAMAGE El DISABLING DAMAGE DAMAGE EXTENT' 1 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. 6 CARGO BODY TYPE 2 LOAD TYPE