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HomeMy WebLinkAbout2025-00069126 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 IIIIII II II II III III I fl III IIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X�00209O u, 1 U21 3 4 1 U1 3 U2 1 U1 1 U2 1 U1 1 U2 1 3 15 U, 1 u2 1 .P0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00069126 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ®Y 0 N 10 22 2025 ❑AM ❑YES ®NO U1 -< DIVISION ST Elgin05:41 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO U2 —I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EouES ❑NW ❑lacv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Sanchez Ma ana.Jose. M. 0 2 / yr 13-UNDER CARRIAGE ©i - FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ONM❑UNK VEH. O AT CRASH IN O 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�B �i COM VEH ❑ Ea 1 0 H 60110 0 1 0 FIRST CONTACT 11 7_: __5 *II Yes.See Sidebar U1 Z FJ95016 IL 2026 REAR TELEPHONE IL D 0 5FNYF6H83NB056425 State Farm ❑Y Igl N U2 63 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same K025477B0913 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ElN 2 0 x DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑NIAV 0 Ncv ❑Dv !1 9 6 6 y Yr Dodge Charger 2017 00-NONE O QI-O DUE TO CRASH p 2 0 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C c ® F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraclion Value 0 POINT OF 8 i1�i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .5 •(ryes,See Sidebar — Elgin IL 60120 0 1 0 AW41870 IL 2026 I 0 Si)c IL D 2C3CDXHG5HH623797 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 3620028SFP13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (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 0 Y U2 Z N 1 ® 11 4 10,22 l2025 05 41 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 25 99 , , ❑PM ❑Construction * Z3 ❑ lyg CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 a ® 11 4 ARREST NAME Sanchez Magana,Jose, M. 11-306 482000593 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility AM r 2 ❑ ARREST NAME 10 t 22 12025 05 41 ®PM ElUnknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 482-Flentye,Jeremy 101 12 , 21 ,025 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 truckrtrailer -< ` ` --I -' r INDICATE NORTH combination):or —I I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver ® } ,• (example:shuttle or charter bus):or C I- <-----I----; ,,,,r, I I } } . transporting employeesned to inthe course passengers or fewer hir employd ment example:employee transporter transports -usually a van type vehicle or passenger car):orCO L L-----}----; I•I On" - 1 } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N --IP r for direct compensation(example:large van used for specific purpose):or __ - — — — — t 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 -- . 1 - CARRIER NAME ADDRESS Z 'Z Not To scale ) T. CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes 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'; 0 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black Green u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Artier/Impound Lot Garage . 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