HomeMy WebLinkAbout2025-00005094 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 III 11001000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0037a861O
u, 1 U21 1 1 1 UI 6 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 12 U2 3 *P 9*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and Ior Tow Due To Crash
0 AMENDED YR 2025I 2025-00005094 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 01 24 2025 ®AM ❑YES ®NO U1 -<
N LIBERTY ST Elgin08:38
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT/MI N E S W PAGE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ RED ❑PEDAL ❑EouES ❑rary ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FOR DAMAGED AREA(S) FRONT TOWED UI
NAME(LAST,FIRST,M) MACAVILCA ROBLES. PABLO 0 mo /7
13-UNDER CARRIAGE 1a i , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 3 M
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8,_iL s 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60120 B 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1
ZET79074 IL 2025 REAR
TELEPHONE
IL D 0 KMHTC6AD2DU092151 AMERICAN ALLIANCE ❑Y ®N U2 m
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
1 99 9 COLMENAREZ SALCEDO. ROMER.J. ILAA-0984324-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m tg DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑r My 0 IKv ❑DV CIRCLE NUMBER(S) U1
2 O 0 2 Honda Accord 2016 00-NONE O' Qi'-_, DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 19( I 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 �1:, 4 COM VEH 0 ® U1 CO
FIRST CONTACT 11 ?A _5 •If Yes.See Sidebar
H ELGIN IL 60123 B 1 0 DR55142 IL 2025 I 0 C
0 1 HGCR2F57GA197501 ALLSTATE ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 99 9 Same 881701760 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph RESPONDER
9 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 4 01 ,24 ,2025 08 38 Ej 0 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)
v 2 0 05 28 01,24 ,2025 08 40 ❑PM 0 Construction
>F
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ®AM ❑Maintenance U2
-a, N ARREST NAME MACAVILCA ROBLES. PABLO 11-708-B 374001290 01,24 i2025 08 44 ❑PM SLMT
1 ® ❑Utility11 4 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME
PENDING
o
Apr vim t 2 0 ARREST NAME 01 r 24 i2025 09 10 MPM ElUnknown work zone type U,
2 2 3 0 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑glvl Workers present? ❑Y 30
374-Rizzu-o. Michael 201 272-Bajak 03 ,04,2025 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.
.. .. , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
r__--; combination):or Z
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r r r (example:shuttle or charter bus):or 0
Not To Scala
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
__-a-_-_I 1MBFAAer� ` 4. Is used ordesi natedtotrans rt between 9 and 15passengers,including the driver, y
I- L.
I I t } } for direct compensation(example:large van used for speific purose):or
L �____a____. WEI.* - i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m
placarding P placards )
Wcartli (example: will be displayed on the vehicle XI
Illici
ikl
t , CARRIER NAME
i ADDRESS 'n
r r -:- 1 1 [I 0
CITY/STATE/ZIP
- MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./GaA. Not in Comm./Other
----- ----- - USDOT NO. ILCC NO. rn
XI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown —I
D
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
to
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
White
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 Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE