HomeMy WebLinkAbout2026-00023945 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 1111 III 11 III1II IIIIII 011111 III 1111 H 01111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV *X004213660*
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 ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00023945 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y 0 N 04 28 2026 ❑AM ❑YES ®NO U1 -<
N STATE ST Elgin05:55
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W W H I G H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
Ii80P,r TOWED U1 Q
Ruffolo. D Ian.J. Chevrolet Silverado 2000 00-NONE 11' 1 DUE TO CRASH 0EN
NAME(LAST,FIRST,M) y mo yr 13-UNDER CARRIAGE 1a.1 2 ' 2 FIRE 0
2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 m
M 2 SYTM IN ENGAGEis-OTHER
4 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF $ 1 B 4 COM VEH 0 Ea 1 0
FIRST CONTACT 12 T. _-5 *Irves.See Sidebar Ut
Z SOUTH ELGIN IL 60177 0 1 0 4308162B IL 2026 ,
TELEPHONE
IL D 1 GCEK19T6YE147246 State Farm ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3817232 SFP 13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
p;rg- DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑ uv 0 NCv ❑Dv
/1 9 9 2 Nissan Rogue 2014 00-NONE 1t"i 12-- DUE DUE TO CRASH 0 C 2
omo 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distracion Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
I S .!.,_4 COM VEH D ® Ut CO
F„ FIRST CONTACT 6 7 _5 •(ryes.See Sidebar C
E LG I N IL 60123 C 1 0 FW87536 IL 2026 FIRST Si)0
M
IL D 5N1AT2MT9EC761364 State Farm ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 2988792-SFP-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER
U1 =
(UNIT) (SEAT) (00B) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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 41 ,81 /026 05 55 ®AM in a Work Zone? lgi N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
453. 2 ❑ 28 99 41 /81 /026 05 56 ®PM ❑Construction E
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
-a, ARREST NAME Ruffolo. Dylan.J. 11-601 1549-000384 41 /81 /026 06 01 Igi PM SLMT
1 ® ElUtilit 11 4 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING
o Ny
r 2 ElARREST NAME 41 /81 /026 06 00 0 PM ElUnknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30
1549-Brown. Bryan 601 337-Thompson 61 / 12 /26 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__--; INDICATE NORTH combination):or
p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
} I I _ } (example:shuttle or charter bus):or
X
Not To Scale 3. Is designed tocarry15fewer passengers and operated a contract carrier O
l- or 9 pe by
es
} } } transporting employees in the course of their employment(example:employee
WN?Highfand?Ave 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 C}-- .-.-; 6 - } } } g po passen rs,includi the dryer,
for direct compensation(example:large van used for specific purpose):or
r
�-i" L I. I I t 5. Is an vehicle used to transport an hazardous material(HAZMAT)that requires
I ri placarding(example:placards will be displayed on the vehicle). iXI
ll
! D
CARRIER NAME Z
Z
ADDRESS 0
r r , ''. 0 1 i i --.: 1
01rTH
n
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- ----.; - USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
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 ❑ 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
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 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Red
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE