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HomeMy WebLinkAbout2025-00070807 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I0110 1111 flIII 1010100I II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004011275 u, 1 U21 3 4 1 U, 1 U2 1 U, 1 1_12 1 U, 1 U2 1 3 11 U1 11 U211 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00070807 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME71 LILLIAN ST ElginSECONDARY CRASH 2 ® ❑ RELATED ❑Y ®N 10 30 2025 ❑AM ❑YES El NO U1 -< PRIVATE mo /day/yr 05:05 ®PM FLOW CONDITION m 010 0/MI N E S © South McLean Blvd COUNTY PROPERTY ❑Y 21 N DOORING ❑Y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q NAME(LAST,FIRST,M) Rosales.Javier mo 3 / 13-UNDER CARRIAGE 19 i ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m M 2 SYTM IN ENGAGE4 ❑Y ®SNE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T :i1 6 4 COM VEH 0 j$J 1 0 ~ Hampshire IL 60140 0 1 0 FIRST CONTACT 12 7_; __5 *IIYes.SeeSidebar Ut Z P 481551D IL 2026 Ismi TELEPHONE IL D 0 1 GT42YEY3J F148831 STATE FARM ❑Y J N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 0484383-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused El El 2 0 g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 Nev 0 DV CIRCLE NUMBER(S) U1 '1 9 9 1 Tesla Model 3 2022 00-NONE ,� 12 , DUE TO CRASH p (� 2 0 13-UNDER CARRIAGE 10 E FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 0 COM VEH ❑ ® Ut CON CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 4 6 :_ FIRST CONTACT 6 O7 ;r0;-__5 •IfYes.See Sidebar FISHERS IN 46037 0 1 0 76403EL IL 2026 aR IN Other 0 5YJ3E1EA8NF322822 STATE NATIONAL INSURANCE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 SHIYANBOLA.SHAKI RAT.A. TLA-IL-A-9999NUMR BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 11 1 10,30 ,2025 05 05 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 S 2 0 28 99 + ) ❑PM• ❑Construction * Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Rosales.Javier 11-601 1551-000242 , r El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM T 2 El ARREST NAME 10 r 30 r2025 05 05 ®PM El Unknown work zone type U1 3O 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1551-Dede.Joseph 602 391-Jacobucci 11 , 18,2025 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••--, , ; 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 -< } }---.r----; } combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n } - } (example:shuttle or charter bus):or C) I . i I li I Not To Scale l 3. Is designed to carry15 or fewer L L A I I 5 passengers and operated by a contract carrier 10 - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L 4. Is used or designated to transport between 9 and 15 passengers,including C }----------; I I - } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O L L____a____. _ _ _ _ _ _ _ _ _ t ii. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires u .,.� placarding(example:placards will be displayed on the vehicle). m —� - - - - �1 Z CARRIER NAME Z I _ ADDRESS I I D It +ad1 rn r I I CITY/STATE/ZIP C) MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. m XI Source of above z . 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 Black White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE