HomeMy WebLinkAbout2025-00078834 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004066649
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 4
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00078834 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
852 N MCLEAN BLVD EIin04:42
® ❑ RELATED ®Y 0 N 12 11 2025 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0
1 1 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 r<r1
F 2 SY5 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S 4 COM VEH 0 j$J 1 0
~ ELGIN IL 60123 B 1 0 FIRST CONTACT 12 7_;1 __S *IrVes.See Sidebar U1
Z FH46171 IL 2025 E
TELEPHONE
IL D 0 SYFBPRHE6EP041707 Statefarm El ®N U2 1-
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 3383894-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV
2 0 0 8 Ford Escape 2015 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C
o Yr 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracl n Value U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S .t. COM VEH ❑ ® W
F.
FIRST CONTACT 6 O7 ,�=Q)OS C.
If Yes.See Sidebar C
HAMPSHIRE IL 60140 0 1 0 FA77651 IL 2025 ARSi)0
IL D 0 1 FMCUOGX1 FU B00951 Progressive ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Evanson. Brian.S. 989078808 SAC E
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)
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 12/11 /2025 04 42 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 28 03 12,11 /2025 04 46 ®PM ❑Construction >F
R 3 ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Calderon. Indra.Y. 11-601 1556000123 12/11 /2025 04 48 Igi PM SLMT AM
N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
t 2 0 11 1 ARREST NAME 12/11 /2025 05 11 ®PM 0 Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 05
1556-Sanchez.Jimena 601 282-St.John 01 ,06/2026 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N ;
i ! 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -<
�' combinationp or
i_ .:.. -:. +
r ----r----, I! -� I - INDICATE NORTH
BY ARROW 2 Is used or desi ned to tran ort more than 15 C
passengers including the driver
W NN, 9hd (example:shuttle or charter bus):or 0
e
; ; I 1 I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
e. Not To Scale r r r transporting employee in the course of their employment(example:employee X
L L.___a__._. I ', I 4alsuorter-sedordesllnatedtotrans vehicle
rtbetween9andr15r) ssen rs,induding[hedriver. C
j _ • } } for direct compensation(examp large van used for specific purpose):or 0
__ _ i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I not" "d placarding(example:placards will be displayed on the vehicle). XI
._ -. —1
CARRIER NAME Z
ADDRESS 0
iiII
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I I I 0 Not in Comm.1GaA. Not inComm./Other
❑ c
;____Y___..; 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
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. 0
White Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/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