HomeMy WebLinkAbout2025-00070777 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 ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
El AMENDED YR 202512025-00070777 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
N RANDALL RD El 02:52
® ❑ RELATED ®Y 0 N 10 30 2025 12,-- ❑YES ®No u1
_ g PRIVATE mo r day r yr ®PM FLOW CONDITION m
FT N E S W BIG TIMBER RD COUNTY PROPERTY ElY ® N DOORING ❑y #OF MOTOR El SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EOUES 0 Nuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Desroches. Dolores. R. 1 0
yr 13-UNDER CARRIAGE fal !. 2 FIRE EllE U2 00 r<
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ It
F 2 SY4 ❑Y ONM❑UNK VEH. 0 AT CRASH 0 IN ENGAGED 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI a 1i 4 C.OM VEH 0 E! 1 C)
~ 6011 0 0 1 FIRST CONTACT 5 O7 .:LQ_OS •IrYes.See Sidebar U1 0
Z Z218246 IL 2026 MAR
TELEPHONE
IL D JTDZN3EU8C3139463 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Desroches.Steven. P. 2461935-SFP-13 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ® N 2 eu
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0!My 0 NCv ❑Dv CIRCLE NUMBER(S) U1
$ 1 9 yf 8 Chevrolet Malibu 2020' 00-NONE O, Qj'-_, DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10 I 2Ic FIRE 0 ® U2 C
P.
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®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 .id.._ 4 C.OM VEH 0 ® U1 CO
F„ FIRST CONTACT 11 7 ----r-_5 •IfYes.See Sidebar C
ELGIN IL 60123 0 1 EY15317 IL 2026 0 Si)
IL D 1 G 1 ZB5ST4LF151715 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same I LAA 1112425-00 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBI (SEX) {SART) (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 10,30 r2025 02 52 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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o",
2 0 2 28 ) r ❑PM• ❑Construction
N 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
-a, ARREST NAME Desroches. Dolores. R. 11-901-A W1506-462 r r 0 PM SLMT
o u1 ® 11 4 CITATIONS ISSUED 0 PENDINGTIME • ❑Utility
o N SECTION CITATION NO. ROADCLEARANCE 0 AM U 45
r 2 0 ARREST NAME Mcdowell. Michael.A. 6-303-A 1506-463 r r PM El Unknown work zone type 1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1506-Nunez. Maria 502 391-Jacobucci 12 +08/2025 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; ; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or -1
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i I , } (example:shuttle or charter bus):or
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3. Is L L.-_------ 1 i. <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_- , < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L-. ..i.. -_.: L L L ...._-.�_ ; l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 0
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
.
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
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
Silver Maroon
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT 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. CARGO BODY TYPE LOAD TYPE