HomeMy WebLinkAbout2025-00081980 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI U� I� II IUI111I111111IIIODU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004097085
u, 1 U210 1 1 3 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 1 U1 1 U299 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY El OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00081980 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
1000 S RANDALL RD Elgin12:00
® ❑ RELATED ❑Y ®N 12 30 2025 ❑AM ❑YES ®NO U1
_ PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 99 Cl)
❑ FT l MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NIAV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Rodri uez Cruz.Jose.A. 0 6 /
yr 13-UNDER CARRIAGE 1U) 2 ' 2 FIRE ❑ IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 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 s :il s 4_5 *Ir Yes.See Sidebar U1 COM VEH 0 Ea 1 0
F. FIRST CONTACT 12 7_
Z SOUTH ELGIN IL 60177 0 1 0 L900245 IL 2026 ,
TELEPHONE
IL D 0 5FNRL5H64DB065588 STATE FARM ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Other 99 Same 682-3910-A11-13A 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
0 DRIVER ❑ PARKED 0 DRIVERLESS El PED 0 PEDAL 0 EWES 0 NUV 0 KCv 0 DV
yr 10 1 12 (, 2 FIRE ❑ ❑ U2 C
0 13-UNDER CARRIAGE
c
M 1 3 ❑Y ❑N El UNK VEH. AT CRASH 99-UNKNOWN •OistractonValue 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 FIRST CONTACT 00 T L=- l. 6 j1:, 5 4 COIfYMes VEH.See Sidebar❑ El
U1 W
• C
= ELGINZ IL 60124 B 1 0 REAR 0 Si)
D
IL D none ❑V 0 N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X
1 64 9 Same NONE BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 5 12,30 /2025 05 41 ®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 �
2 ❑ 18 99
N 3 ❑ CITATIONS ISSUED 0 PENDING + ! ❑PM• El Construction >E
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / _ ID PM
1 ® 1 2 1 UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
0 AM
T 2 D ARREST NAME 12 r 30 /2025 12 00 0 PM ElUnknown work zone type U1 10
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 2 3 ❑ - ❑AM Workers present?
1 Solis• Laura sot , ❑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----; ( INDICATE NORTH combination):or —I
Not To Seale ) p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
—N D 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
`----------i I• 700r1?RandelPRD I - } } } transportingemployees in the course of their employment
pbyment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
C
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
I I t } } for direct compensation(example:large van used for speific purose):or o
L i. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
MI placarding(example:placards will be displayed on the vehicle).
' —1
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above Z
—I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill 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 VIN 1 m
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
Silver
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE