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HomeMy WebLinkAbout2025-00070926 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets _ 01111101111 10110 ll ,1111 1100lI11001 lI�00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�015341 u, 1 U2 1 1 1 U1 4 U2 U, 1 U2 U, 1 U2 1 1 9 U1 15 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ® 6 Injury and for Tow Due To Crash YR 202512025-00070926 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 1500 N RANDALL RD Elgin® ❑ RELATED ❑Y ®N 10 31 2025 ®AM ❑YES N NO U1 —< 10:09 _ PRIVATE mo /day/yr ❑PM FLOW CONDITION M_ COUNTY PROPERTY N Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 cn ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!Cy 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FROM TOWED U1 O Perez. Marcelo. E. 0 1 / yr 0-UNDERCARRIAGE ©,I 0,•: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 N U2 20 m M 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH 0 IN ENGAGEDis-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1,.4 COM VEH 0 N 1 0 ~ ELGIN N I L 60120 0 1 FIRST CONTACT 12 7 ; _S *Irves.See Sidebar Ut Z FM99533 IL 2025 REAR TELEPHONE IL D 0 J M 1 BK32F871707325 Progressive ❑Y Il N U2 M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 861 799 939 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ❑ N 2 XI 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 NCv 0 Dv yr 10 j 12 c 2 FIRE 0 N U2 C _ 13-UNDER CARRIAGE Ti AUTOMATION LEVEL LEVEL 4-TOTAL(ALL) DISTRACTED 0 ® SPDR n SEX SAFT AIR 0 0 9!1,6•TQp * 0 SYSTEM IN ENGAGED 15-OTHER a ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN Oistracton Value 9 g POINT OF 8 i 4Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR J 6 j',_p COM VEH 0 N CO FIRST CONTACT 3 7_ • •IfYes,See Sidebar H BSOE47 IL 2025 I g fn M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4S3BWAD60S3027311 Travelers Ins 0 V N N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Subaru AD7T97235724 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z N 1 ® 18 5 Subaru Light Pole 10,31 /2025 10 09 ®❑PM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 2 ❑ 1500 N RANDALL RD ELGIN IL 60124 20 28 10,31 /2025 10 10 PM ❑ ❑Construction * 4 R O 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 3 ®AM ❑Maintenance U2 o El 11 5 ARREST NAME Perez. Marcelo. E. 11-601 260-01771 10/31 /2025 10 18 ❑PM• El Utility SLMT B!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM r 2 El 18 5 ARREST NAME Perez. Marcelo. E. 11-709-A 260-01770 10/31 /2025 10 20 [�PM 0 Unknown work zone type U1 30 ut 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 260-Sheehan.Joseph 901 11 , 18,2025 09 00 ❑PM N 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 -' I. INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ - } (example:shuttle or charter bus):or Not To Scale 1 ' 0 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I } } } transporting employees in the course of their employment(example:employee X __ 1 I t[._ J 1 I t - transporter-usually a van type vehicle or passenger car):or w I 4. Is used or designated to transport between 9 and 15 passengers,including C-a_ I. } for direct com nation exam I lar a van used for s cific ur o ):or the driver, Pe ( P 9 Pe P pos ):or _aicoortstl L____a..... — I - L L I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires '0 `\•,,� m placarding(example:placards will be displayed on the vehicle). XI M 1 I - ��-- /,,.+E. ,{I/, I CARRIER NAME Z a / __ ADDRESS 1 O ® } D tw.gmrm,t/ C) CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ;....Y. ._; - USDOT NO. ILCC NO. m XI Source of above z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g 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 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 Black Blue 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE