HomeMy WebLinkAbout2025-00059588 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 O
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00059588 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 21 m® ❑ RELATED ❑Y ®N 09 10 2025 ®AM ❑YES ®NO U1
DUNDEE AVE Elgin PRIVATE mo /day/yr 10:30 ❑PM FLOW CONDITION m
el ®!MI N E 0 W CONGDON Ave COUNTY PROPERTY ❑Y 21 N DOORING ❑Y #OF MOTOR 0 SLOW 6 Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
T TOWED U1 0NAME(LAST,FIRST.M)
PADILLA. EUSTACIO mo
yr 13-UNDER CARRIAGE 10 �. 2 FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 3 M
M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 iL a 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60124 0 1 0 FIRST CONTACT 00 7_; _5 *II Yes.See Sidebar Ut
Z 188678 IL 2026 REAR
TELEPHONE
IL D 0 3GDKC34F21 M117573 PROGRESSIVE ❑Y J N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 947870821 6 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 21 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 KIcv ❑DV
1 9 yf 3 Mack Trucks. Ildoknown 2018 oo-NONE O, 12.._, DUE TO CRASH ❑ ® 14 73
o 13-UNDER CARRIAGE 10 1. 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 3
POINT OF s i COM VEH ❑ ® CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 LI:- C
FIRST CONTACT 11 7 , _5 •(ryes.See Sidebar
n AURORAZ IL 60504 0 1 0 42297V IL 2026 REAR Si)0
IL A 7 1 M2AX04C6JMO38052 LIBERTY MUTUAL ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 10 =
99 9 VCNA PRARIE LLC AS2-651-291674-034 BAc $
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)
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/ U1 1 D
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 09,10 /2025 10 30 ®❑AM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 28 12
N 3 0 0 CITATIONS ISSUED 0 PENDING / / 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME / / _ ❑PM '
1 ® 11 1 0CITATIONS ISSUED ❑PENDING • UtilitySLMT
oN SECTION CITATION NO. ROAD CLEARANCE TIME 0
_ AM u1 25
t 2 ❑ ARREST NAME 09 t 1 0 12025 1 0 30 [�PM 0 Unknown work zone type
i T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - El AM Workers present? 0 N 25
374 Rizzu o. Michael 102 / 0 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- r , / / it f ' r 1.
Has atio eig):hht t rating more than 10,000 pounds(example:truck or truck trailer -<
f INDICATE NORTH p1
opgeOraAVE BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
— — _ } (example:shuttle or charter bus):or
X
3. Is desgned to car 15 or fewer passengers and operated a contract carrier O
L <.___A_._ -: } } } transporting employees In thecoursee of their employment(example:employee X
• ___./ �/ transporter-usually a van type vehicle or passenger car):or co
C
L L.___a____' P N •4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
} } } for direct compensation(example:large van used for speific purose):or N
L L____a____� - I r L L L 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
/'.
placarding(example:placards will be displayed on the vehicle).
0
/ / Not lb Scab l - __
CARRIER NAME XI
_ ADDRESS 'n
/ / �r�EE„ T.
to
/ / CITY/STATE/ZIP
g
/ �/ - 1 MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T ❑ Not in Comm./Govt. Not in Comm./Other
; _ _ __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. XI
XI
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
Red White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE