HomeMy WebLinkAbout2025-00059138 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 I0H
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XCO3951492
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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 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00059138 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 m
235 S MCLEAN BLVD El In 03:42
® ❑ RELATED ❑Y ®N 09 08 2025 ❑AM ❑YES El NO U1 —<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT l MI N E S W 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 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 9 !
yr 13-UNDER CARRIAGE IE
101 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL B 1i 4 COM VEH ❑ Ea 1 0
F. FIRST CONTACT 1 7 ;—_;__5 *Iryes.See Sidebar U1
V Z Carpentersville IL 60110 0 1 0 24803Q IL 2026 REAR
TELEPHONE
IL A 7 1 HTSHAAR7SH657342 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
EIPro Conrete and Pa G854575-E06-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0
!1 9 yf 4 Nissan Sentra 2024 00-NONE i1_"j 12 NT..-_, DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10'( 2 FIRE ❑ El U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O1 S Y0 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 5 O7 �,�_Q)OS •byes.See Sidebar
ELGIN Z IL 60123 0 1 0 FL49664 IL 2026 AR 4 N
M
IL D 0 3N1AB8DV1 RY283923 Progressive ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 998679560 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 09,08 /2025 03 42 ®pm in a Work Zone? Igi N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 ❑ 03 28 , / 0 PM ❑Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Robles. Misael 11-601-Ax 1525000743 / ! ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
AM
t 2 ❑ ARREST NAME 09/08 12025 04 21 ®PM ElUnknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1525-NavE.Oscar 601 10 ,28/2025 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
�x ADDITIONAL UNITS FORMS.
r ----r••--, , N . A CMV is defined as any motor vehicle used to transport passengers or property and: Z
II
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
- -----------' r I • INDICATE NORTH combination):or -I
I
Not To Scale J
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
i_ - } • (example:shuttle or charter bus):or 0
I- L.___A.._.� I 3. Isdesgnedto carry 15or fewer passengers and operated bya contract carrier O
I. } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or
' . 4. Is used or designated to transport between 9 and 15 passengers,including (I)
i. i. __}----; - } } } g po passen rs,includi the driver,
2 for direct compensation(example:large van used for specific purpose):or O
' L___-a..... I ' - - I 1 t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
'D
placarding(example:placards will be displayed on the vehicle). XI
KVi CARRIER NAME Z
ADDRESS
• CITY/STATE/ZIP n
g
_ MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
USDOT NO. ILCC NO. rn
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? 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE