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HomeMy WebLinkAbout2025-00076223 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 111110110 �NI� �Ill Oil DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004045303 u, 1 U21 3 4 1 U116 U2 1 U, 1 u2 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00076223 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED PRIVATE ❑Y ®N 11 28 2025 ❑AM ❑YES IX]NO U1 —< S RANDALL RD Elgin mo /day/yr 02.01 ®PM FLOW CONDITION Ill • 1 O(1 COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 1 (n ® �C.7!MI N E O W Weld Rd WITH VEHICLES INVLD 0 STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) FOR DAMAGEDAREA(S) FROr T TOWED EN U1 0Zarate Madri al.Jesus 1 0 / yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il a 4 COM VEH 0 j$J 1 0 I— 60110 0 1 0 FIRST CONTACT 12 7 ;1 _5 *IIYes.SeeSidebar Ut ZFJ91625 IL 2026 Ismi TELEPHONE IL D 0 1 G 11 B5SL2FF337173 American Alliance ❑Y Il N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same I LAA-1117684-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 Ncv 0 Dv /1 9 6 3 Hyundai Elantra 2020' 00-NONE 11_"j t2 -_, DUE TO CRASH ❑ (� 2 0 13-UNDER CARRIAGE 10'I ( 2 FIRE 0 ® U2 C Ti F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .I. COM VEH ❑ ® tit CO FIRST CONTACT 6 O7 ,�=Q)OS •If Yes.See Sidebar C ELGIN IL 60123 0 1 0 AX73075 IL 2026 i 0 Si) Z IL D 5NPD84LF2LH540538 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 0239557-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 11 / F 2 4 0 1 0 m / / #OCCS D 7/ / / UI 2 D / / 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 11 /28 /2025 02 01 ®pm in a Work Zone? ®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 o" 2 28 99 / / ❑PM• ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Zarate Madrigal.Jesus 11-601-Ax 1547000166 / / El PM SLMT o N • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 45 t 2 ❑ ARREST NAME AM 7 ( / pM El Unknown work zone type U1 2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1547-Steele.Justin 702 01 (06/2026 09 00 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 A ADDITIONAL UNITS FORMS. r ----r••--, , Not To Scale 1 N - % A CMV is defined as any motor vehicle used to transport passengers or property and: lllo "'` - 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer c ` --1 -' r INDICATE NORTH combination):or -I - - - - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C j. - } (example:shuttle or charter bus):or X 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O } A i (Woliffv) } } } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or 03 L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or ' L_ fmwrr�ae) < I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires link z !I ✓ placarding(example:placards will be displayed on the vehicle). m A S .1 i CARRIER NAME Z I. L. ADDRESS O {Mirk 0 CITY/STATE/ZIP g 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. rn XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI XI Did HAZMAT spit 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 VIM 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 Blue Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE