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2025-00000983
ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 II OlD III Dl 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036a5564 u, 1 U21 1 1 1 U, 7 U2 1 U, 1 u2 1 U1 1 u2 1 1 11 U1 1 U2 1 *P 0 11 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00000983 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m® ❑ RELATED PRIVATE ❑Y ®N 01 05 2025 El AM ❑YES ®NO U1 -< RT20 WB Elgin mo /day/yr 11.47 ❑PM FLOW CONDITION m IO ®!MI N E S ® East State St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n f'rr TOWED U1 0Padilla Es aria. Luis.A. Ford Mustang 2007 00-NONE • 2 0 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) p mo yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 5 ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I,.4 COM VEH ❑ 0 1 O ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 • _-5 *If Yes.See Sidebar U1 ZEV21030 IL 2025 TELEPHONE IL D 0 1ZVFT82H575255143 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 3394475-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 eu x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KDV 0 DV 2 Yr O O 2 Nissan Rogue 2018 00-NONE 10' t2 (,-2 FIRE DUE D CRASH ® U2 2 cXj o 13-UNDER CARRIAGE El c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraelion Value 9 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 at.t. 4 COM VEH D El Ut W FIRST CONTACT 6 O7 ,�= )OS •If Yes.See Sidebar C ELGIN IL 60120 0 1 0 BE36384 IL 2025 0 Si) IL D 0 J N 1 BJ 1 CR8JW282623 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Shaoul. Rony.W. 0463414-SFP-13 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 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 ®Y U2 Z N 1 ® 11 1 1/ ,/2 (25 11 47 ®❑PM AM in a Work Zone? ❑N DIRP D co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 O 2 0 28 03 ( ( 0 PM ®Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. • EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Padilla Esparza. Luis.A. 11-601 S1540-000071 ( r El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility El AM t 2 El ARREST NAME 1/ (/2 125 01 05 ®PM 0 Unknown work zone type U1 55 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1540-Allahi. Muhammad 701 275-Engelke , r 0 AM Workers present? ®N U2 55 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- }__-_r_-_-; INDICATE NORTH combination):or P3 ""'a'�"a BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or n ® ® t Q 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 `----A --- -i a I. } } transporting employee in the course of their employment(example:employee X or co L L.___a____1 42lsuosedordrter- signatedtotranslly a van type portbetweeicle or n9a d15enger rpassen rs,includingthedriver, C } } for direct compensation(examp large van used for specific purpose):or 0 L L--_-a a°"'12 0 - l. i. i L 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 Z ADDRESS 0 A D I rn N CITY/STATE/ZIP n 0 Noe To scare ) MOTOR CARR.ID 0 Interstate El Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other i— --- --1 - USDOT NO. ILCC NO. m XI Source of above z If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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 Black 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE