HomeMy WebLinkAbout2025-00076219 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 111111/ 1/ Ill 0 000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�068/68
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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 1215501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00076219 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 r1
® ❑ RELATED t8I Y 0 N 11 28 2025 DAM ❑YES ®NO U1
S RANDALL RD Elgin 01:19
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
FT!MI N E S W SPARTAN DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 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 T TOWED U1 0
NAME(LAST,FIRST,M) Szwarga. mo yr
David. R. Honda Odyssey 2010 00-NONE 11. (2)' 1 DUE TO CRASH ❑
13-UNDER CARRIAGE FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 VI
O DISTRACTED 0 ]Si U2 2 rn
M 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASHO 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_i� a 4 COM VEH ❑ Ea 1 0
I . Hampshire IL 60140 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.SeeSidebar U1
Z P V461391 IL 2026 Ismi
TELEPHONE
IL D 0 SFNRL5H37GB109349 State Farm ❑Y IlN U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 2606892SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 iiuv 0 i v 0 DV
/1 9$7 Other Other 2019 00-NONE 1("j 12..-_, DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10'I c. 2 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 al :; COM VEH ❑ ® tit CO
FIRST CONTACT 6 v ,�= -.-5 •IfYes.SeeSidebar
ELGIN IL 60120 0 1 0 FN37937 IL 2026 i 0 C
IL D 0 Liberty Mutal ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Rosario Quinones.Jorge Albe A0V24304327790 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DORI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 11 /
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 co
11 /28 /2025 01 19 ®PM AM in a Work Zone? ®N DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
O 2 ❑ 03 99 / / ❑PM ❑Construction
" 3 ❑ xi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 8
-, ® 11 1 ARREST NAME Szwarga. David. R. 11-601-Ax 1528-000321 / / El PM SLMT
o Nu ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
El AM
T 2 El ARREST NAME 1 1/28 /2025 02 00 0 PM El Unknown work zone type U1 3O
2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1528-Rivera. Kevin 702 12 /22/2025 01 30 ®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 -<
} }---.r----; combination)or
II INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
- } (example:shuttle or charter bus):or
X
L A 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
un rz transporter-usually a van type vehicle or passenger car):or CO
L L.___a____� s0°pe7O 4. Is used ordesi natedtotrans transport passengers,including C- } } } g po passen rs,includi the driver,
unm� for direct compensation(example:large van used for specific purpose):or O
f l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
a placarding(example:placards will be displayed on the vehicle).
\ CARRIER NAME Z
__ ADDRESS
0
CITY/STATE/ZIP 0
0
-_Not To Scab J _ i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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
Bronze
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE