HomeMy WebLinkAbout2025-00062269 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00062269 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 �1
® ❑ RELATED ®Y ❑N 09 22 2025 ❑AM ❑YES ®NO U1 -<
SPAULDING RD Elgin02:10
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W G I FFORD RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl)
❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C)
FOR DAMAGED AREA(S) Mao TOWED U1 Q
Patel.Chandulal.A. 1 1 /
yr 13-UNDER CARRIAGE IE
10 •!! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 00 r<n
M 2 SYTHER
6 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN ENGAGED 0 99-UNKNOWNU 9 76-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iII 6 ll o COM VEH 0 1E 1 C)
H 1- HOFFMAN ESTATES IL 60192 0 1 0 FIRST CONTACT 5 7:_:LQ_Q •Il Yes.See Sidebar U1 0
ZDX79145 IL 2026 mai
TELEPHONE
IL D 0 4T4BF3EK2AR038232 ALLSTATE ❑Y ®N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Elgin Fire 99 9 Same 811272823 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y ElN 2 0
N DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 MAV 0 KCv 0 DV
1 9 6 0 Freightliner Cdfp.D120 2000' 00-NONE 0. Q!'-O DUE TO CRASH ❑ ® 98 x
0 y Yr 13-UNDER CARRIAGE 10( I E FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH El 0 U1 W
FIRST CONTACT 12 7 .5 •It Yes.See Sidebar
4 ELGIN IL 60120 0 1 0 26220V IL 2026 I 0 C
IL A 7 1 FUYDSYBXYMF48239 Geico ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 9300081251 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (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 ❑Y U2 Z
N 1 ® 11 4 09/22 ,2025 02 10 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 2 15 09,22 ,2025 02 44 ®PM 0 Construction *
R O ❑ ]$I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Patel.Chandulal.A. 11-901-A 1561-000088 09,22 r2025 02 51 ®pM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
t 2 El ARREST NAME 09!22 12025 03 09 ®PM El Unknown work zone type U1 0 AM
45
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1561-Sarovic, Mirko 401 11 ,04,2025 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
ADDITIONAL UNITS FORMS.
Y.•--, I Not To Scale I 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 truckrtrailer -
i- i•---_-:-----; (ND
INDICATE NORTH combination):or 1
BY ARROW2 Is used or designed to transport more than 15 passengers including the driverC
_ (example:shuttle or charter bus):or
X
i. i. ..;-•--; �p�wt� I
- transporting3. Is tlgemoloyeesl5 or fewer in the coursepassengers
�rye etStrantlyment example:employee a contract der
} } } p employment
yV / transporter-usually a van type vehicle or passenger car):or CO
C
L L.___a__ / ® - 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
} } } for direct compensation(example:large van used for specific purpose):or 0
L L____a____. L L t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
'�T.
placarding(example:placards will be displayed on the vehicle). m
0
CARRIER NAME CHAPULIN TRUCKING INC Z
® ADDRESS 815 MARTIN DR D
to
I CITY/STATE/ZIP ELG I N 1 I LJ 60120 w
o
_ i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ti i. i. ❑ Not in Comm./Govt. 0 Not in Comm./Other
�---------1 - USDOT NO. ILCC NO. 164487
x
Source of above z
. 0 Yes II No ❑ Unknown A
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 ®No 2
TRAILER VIM 1 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 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray White
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