HomeMy WebLinkAbout2025-00053811 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 0110
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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 ❑5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED YR 202512025-00053811 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2
® ❑ RELATED ❑Y ®N 08 18 2025 ®AM ❑YES ®NO U1 -<
VILLA ST Elgin10:07
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W ILLINOIS AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NIA/ 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROf'rr TOWED U1 Q
Solarzano. Ruben 1 1 /
yr 13-UNDER CARRIAGE NI
10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 rn
M 2 SYTHER
4 ❑Y ON UNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 76-TOP S `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH El j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 4 7 ; __5 *II Yes.See Sidebar Ut
Z 3179191B IL 2026 E
TELEPHONE
IL D 0 1 FTFW1 EF7G FB55812 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1639832-SFP-13 1 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
0 DRIVER 0 PARKED 0 DRIVERLESS N PED 0 PEDAL 0 EWES 0 NMy 0 Ncv 0 DV
yr 12 - C
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
c
M 1 3 ❑Y El
IN ENGAGED 15-OTHER 9 16-TOP 3 0 X
❑N UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI 6 _4 COM VEH ❑ ® U1 W
FIRST CONTACT 6 Y :j- -5 •If Yes.See Sidebar C
m ELGIN IL 60120 B 2 8
0 Si)
Z
IL D 0 ❑Y ❑N RDEF 7:1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 56 10 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph D Y°®N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
W 1 2 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 1 Castillo.Adolfo. I. Electric Scooter 08,18 /2025 10 07 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 0 705 SHERMAN AVE ELGIN IL 60120 20 18 08,18 ,2025 10 07 ❑PM ❑Construction
*
R 3 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ELMS ARRIVED TIME
z J ®AM ❑Maintenance U2
o ® 12 1 ARREST NAME Solarzano, Ruben 11-709-A 1560000062 08/18/2025 10 10 ❑PM• El Utility SLMT
B!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 El ARREST NAME Solarzano. Ruben 11-402-A 1560000061 08/18 /2025 10 20 MPM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1560-Jones. Bennett 401 10 ,07,2025 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
t vino st ADDITIONAL UNITS FORMS.
r ----r••--, , I ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i•____r____; I 1. Has aor more than pound (example:truck or trucktrarler
1. Hasa weight rating10 000 5 i
Ilfinoie?Ave INDICATE NORTH combination): .Z-<
�1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ (example:shuttle or charter bus):or C
I- <-----I----; — - transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employeener X
Itransporter-usually a van type vehicle or passenger car):or w
L }-----}----; > } 1.
> - } 4. Is used or designated to transport between 9 and 15 passen including the driver. N
for direct compensation(example:large van used fors specific purose):or
` I
< < < t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
`�Z placarding(example:placards will be displayed on the vehicle). III
XI
I 1.
— - CARRIER NAME Z
` I ADDRESS 0Not To Scale 1 i w
CITY/STATE/ZIP g
- MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I r I Iji-- N0 0 Not in Comm./Govt. Not in Comm./Other O
:- ‘I. --- --; !1 1. L L
USDOT NO. ILCC m
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?
❑ Yes II No ElUnknown A
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE