HomeMy WebLinkAbout2025-00076281 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets IIIIII H I M 11111111 II 11111111l11I1 DD
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004049891
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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 ❑5501-51.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00076281 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
S RANDALL RD Elgin 06:33
® ❑ RELATED ®Y 0 N 11 28 2025 ❑AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W SOUTH ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGED AREA(S) FROM TOWED U1 Q
Rodri uez. Ben amin 1 1 /
yr
13-UNDER CARRIAGE 10 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 rrl
M 2 8 ❑Y ®N SYSTEM
❑UNK VEH. AT CRASH 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il_6 I, 4 COM VEH 0 LK 1 0
~ ELGIN IL 60124 C 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.See Sidebar U1
Z FM39314 IL 2026 REAR
TELEPHONE
IL Other 0 1 HGCR2F51 DA237308 StateFarm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 0362917SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y El 2 ou
Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES 0 iiuv 0 KCv ❑Dv
yr 12
0 13-UNDER CARRIAGE 10( z FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i 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 6 Il, COM VEH ❑ ® U1 W
FIRST CONTACT 1 7 . -5 •If Yes,See Sidebar
- HAMPSHIRE IL 60140 0 1 0 3726653B IL 2026 REAR9 Sn
Z
IL D 0 1 C6RR7GT3FS509736 Country Financial ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same P010714357 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
ut =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
1 4 07 /
' 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 4 11 ,28 /2025 06 33 ®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
v 2 0 2 99 11,28 ,2025 06 34 ®pM ❑Construction
R O 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
o 1 ® 11 4 ARREST NAME Rodriguez. Benjamin 11-901-A 1530000527 11,28/2025 06 41 ®pM• • El SLMT
ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
t 2 El ARREST NAME Luna Robles. Francisco 11-708 1530000528 1 1/28 /2025 07 15 ®PM 0 Unknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1530-Soto.Oscar 702 01 ,06/2026 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 truck trailer -<
` ` '' -' I I r INDICATE NORTH comb natlon)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
`* I �. r X
. nu rb-.r c j 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } 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 N
-- -- L! - } } } g po passen rs,includi the driver,
v for direct compensation(example:large van used for specific purpose):or O
11 t 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
® CARRIER NAME Z
4-� Untt2 - i. __ ADDRESS 0
CITY/STATE/ZIP 00
I - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
.
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'; 0 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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/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