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HomeMy WebLinkAbout2025-00068856 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 1111 1011111111111 111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0040D0790' u, 1 U21 1 1 2 U, 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2025-00068856 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 1600 N STATE ST Elgin04:44 ® ❑ RELATED ❑Y ®N 10 21 2025 12,— ❑YES ®NO U1 -< _ PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 ' ❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q Benavides Lo ez. Marvin.J. 1 2 / yr © 13-UNDER CARRIAGE 19 i ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 m M 2 4 SYSTM❑Y IN NE DUNK VEH. O ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 :i1 6 �i,4 COM VEH ❑ j$J 1 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7_; __5 *Ilves.See Sidebar U1 Z EZ12101 IL 2025 E TELEPHONE UNK. D 0 1 B3HB48B07D374669 Unique Insurance Co ElJ v N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co 99 9 Same ILP2882071 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 X m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KCv ❑DV !1 9 6 8 General Motor'd;?ilapl 2020' 00-NONE ,t-1 12..-_, DUETO CRASH ❑ 2 73 o yr 13-UNDERCARRIAGE tal 2 FIRE 0 El U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y EQ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac Dn Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8i 6 ....4 COM VEH ❑ ® u1 CO FIRST CONTACT 6 7A-�-"05 •If Yes.See Sidebar C ELGIN IL 60123 0 1 0 BT30276 IL 2026 REAR 0 Si) Z IL D 0 3GKALVEV6LL158335 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 0847387-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SART) (AIR) (INJI (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 0 Y U2 Z N 1 ® 11 1 10,21 /2025 04 44 ®pm 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 o" 2 0 28 11 ! ! ❑PM• ❑Construction >F R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 -a, ARREST NAME Benavides Lopez. Marvin.J. 11-601 S1542-000513 ! ! El PM SLMT oN 1 2111 1 •igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility r 2 0 ARREST NAME Benavides Lopez. Marvin.J. 6-101 S1542-000512 10!21 ,2025 05 23 ®PM ❑Unknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1542 Chafe. Ethan 501 391-Jacobucci 11 ! 17,2025 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 ADDITIONAL UNITS FORMS. r ----r•---, , Not TO Scale I 0 . 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 truckrtrailer -< i- }-- --I-- --' r INDICATE NORTH combination):or -I 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 carry 15 or fewer passengers and operated a contract carrier O < }.___A.._.� ` - y } } } transportingemployees In the course of their employment — _ 1 transporter- a van vehicle or (example:employee w Po usually type passenger car):or L 4. Is used or designated to transport between 9 and 15 passengers,includingN -- } } } g Po the driver, — 1 for direct compensation(example:large van used for specific purpose):or O L L____a.....I - t i. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ` placarding(example:placards will be displayed on the vehicle). ;p lhitI -- _I i ( G)l� CARRIER NAME Z ' ' ADDRESS 'n' ! w f > n J f CITY/STATE/ZIP 0 rIntl J MOTOR CARR.ID ❑ Interstate ❑ Intrastate. I . . ! ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 � "Y""1 USDOT NO. ILCC NO. C m XI 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 to 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 Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. _Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE