HomeMy WebLinkAbout2025-00071714 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 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/or Tow Due To Crash
0 AMENDED YR 202512025-00071714 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 11 04 2025 ®AM ❑YES ®NO U1
DUNDEE AVE Elgin 11:41
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITT
FT!MI N E S W CH ESTER AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn
❑ 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 ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
1 1 /
yr 13 1t. 12 _+ OUE TO CRASH ® ❑
13-UNDER CARRIAGE 9 i I! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0U2 1 r<r1
F 2 4 ❑Y ®SNEM❑ 15-OTHER
UNK VEH. O AT CRASHD O 99-UNKNOWN 00 TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a .
m H ELGIN IL 60120 0 1 0 FIRST CONTACT 9 7 D;i:� �' 4 COM VEH ❑ Ea
__5 .II Yes.See Sidebar Ui 1 O
Z AYD7386 WI 2026 ' E
TELEPHONE
IL D 0 2HGFG12607H570259 unknown ®Y ❑N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Rodriguez. Laura unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
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g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
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.0 13-UNDER CARRIAGE 10( 1i 2 FIRE ❑ ® U2 C
P.
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y Ni N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7A -5 •If Yes.See Sidebar
H ELGIN IL 60123 0 1 CT85272 IL 2026 I 0 C
IL D 0 4T4BF1 FK7ER390022 Auto Owners ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 44-977852-07 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
2 3 1 2 / F 2 3 0 1
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/ / #OCCS D
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u N 1 ® 11 1 11 ,04 /2025 11 14 ®p PM AM in a Work Zone? ®N DIRP D
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1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 n
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2 ❑ 2 99 , / ❑PM. ❑Construction
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Rodrigues,Selena, M. 11-1204-B 748270 , / El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
8 N ❑AM 30
t 2 ElARREST NAME Rodrigues,Selena, M. 3-707 748269 , / ❑pM ElUnknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1531-Sch'c mbach.Jack 201 12 ,08,2025 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 -<
i- }-_-_r-_--; AT combination):or
INDICE NORTH P1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
IV _ (example:shuttle or charter bus):or
< <----- ----; I ( - transporti3. Is g em lloyeeo slin the course of 5 or fewer theirersnanodyment(example:employee
a contract ner
0—Not To Scale } r } transporter g-usually a van type vehicle or passenger car): r w
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} } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
� for direct compensation(example:large van used for specific purpose):or O
< .l. — _ t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires �
I !_I } .} I placarding(example:placards will be displayed on the vehicle). XI
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r . 1. L. 1..- CARRIERADDRESS NAME Z
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CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate 0 Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
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
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LOCAL USE ONLY TRAILER VIN 2 m
0
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
Black Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
_Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE