HomeMy WebLinkAbout2025-00055817 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X40393540
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00055817 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 08 26 2025 ®AM ❑YES ®NO U1 -<
WAVERLY DR Elgin 08:15
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT l MI N E S W JOSLYN DR COUNTY PROPERTY ®Y ❑ N DOORING ❑y #OF MOTOR ❑SLOW Cl)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 7 !
yr
Kia Motors Cotjtptima 2012 00-NONE DUE TO CRASH
1 t, 12 t ® ❑
13-UNDER CARRIAGE 101 !! 2 FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-U 15-UNKNOWN THER9 t6•TOP�3 `Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,.4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_: _-5 *II ves.See Sidebar U1
Z DE94106 IL 2026 REAR
TELEPHONE
IL D SXXG R4A6XCG002436 Progressive ❑v ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Rodriguez Delapaz. Leobardo 978243565 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 Kcv 0 DV
yr 12 _ X1
o 13-UNDER CARRIAGE 10.i :., 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction
value U1 4 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 1j._5 CIO es See SidebarEH
❑ C
CO
F` REAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 145 A
RESP❑YDNDER❑N U1 =
(UNIT) ISEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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m
Pj
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 36 2 Alexander.Ashley. M. Grass in the front yard. 08/26 ,2025 08 15 ®❑pM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
v t 2 ❑ 295 WAVERLY DR ELGIN IL 60120 28 08 ! ! ❑PM ❑Construction >F
Z3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Rodriguez.Alexis 11-601 747536 ! ! El PM
o u 1 ❑ �(CITATIONS ISSUED ❑PENDING TIME ❑Utility SLMT
o N SECTION CITATION NO. ROAD CLEARANCE AM 30
t 2 ❑ ARREST NAME Rodriguez.Alexis 6-303-A 747535 ! ! DI PM El Unknown work zone type U1
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1557-Wieske. Nathan 202 09 ,24/2025 10 30 El NI ®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-----; ss5rnavenr'ror. N - } combination):or —Ic INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N - } (example:shuttle or charter bus):or
X
\ 3. Is designed tocarry15 fewer passengers and operated a contract carrier O
` eS or
-- -- \ - } } } transporting employees in the course of their employment� (example:employee � X
transporter-usually a van type vehicle or passenger car):or w
L }-----i.. ..I. \ ; / • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
. / for direct compensation(example:large van used for specific purpose):or
L �____a____� \ / l. I. 1 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m
/ lyn?Dr. placarding(example:placards will be displayed on the vehicle). ;p
/ CARRIER NAME Z
� ADDRESST.
'n
rn
\ CITY/STATE/ZIP 0
_Not 70 ScalpJ WaveAy?Dr. \ _ MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE