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HomeMy WebLinkAbout2025-00005005 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111 I01101100 0 II IIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00370673 u, 1 U21 3 4 1 u1 2 U2 1 u, 1 u2 1 u, 1 U2 1 5 10 u1 3 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 ❑5501-51,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00005005 VENT ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n RT20 RELATED ®Y 0 N 01 23 2025 05:47 ❑AM ❑YES ®No U1 -< Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION ITl FT!MI N E S W LAMBERT LN COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ Cook 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 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 1 FOR DAMAGEDAREA(S) FROnrr TOWED U1 O NAME(LAST,FIRST,M) Kavaliunas. Loreta mo /1 9 5 4 Tesla Model 3 2021 00-NONE „_' ©' ODE TO CRASH ® ❑ 13-UNDER CARRIAGE FIRE 0NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O THERDISTRACTED 0 0U2 0 ffl F 2 SY8 ❑Y ❑STM NE®UNK VEH. 9 ATCRASHD g 99-U 15-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :i1;� �i,4 COM VEH 0 j$J 1 0 F. FIRST CONTACT 1 7_ a-_;__5 *IIYes.See Sidebar U1 Z CHICAGO IL 60610 0 1 0 35725EL IL 2025 is TELEPHONE IL D 0 5YJ3E1 EBOMF979508 Bristol West ❑Y IlN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same G01-3822471-02 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑DV !1 9 yf 4 Ford Escape 2010' 00-NONE ,._"i Qj`O DUE TO CRASH rg ❑ 2 x .. 13-UNDER CARRIAGE I I, FIRE 0 ® U2 C c F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracuon Value 9 g POINT OF s 1 4 COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _ij 6 i' C FIRST CONTACT 1 7�. -5 •If Yes,See Sidebar Z Streamwood IL 60107 0 1 0 Q552273 IL 2025 REAR 0 Si) M IL D 0 1 FMCU9DG4AKC86496 American Freedom ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 12-2436614-01 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJ) (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS),(TELEPHONE) (EMS) (HOSPITAL) 2 3 02 / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 01 ,23 ,2025 05 47 ®AM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 0 2 99 O1,23 ,2025 05 52 ®pM ❑Construction >F R O 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ❑AM ❑Maintenance U2 a ® 11 4 ARREST NAME Kavaliunas. Loreta 11-901-A 474000591 01,23/2025 05 57 Igi pM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility El AM r 2 ElARREST NAME 01 r 23 r2025 06 35 ®PM ❑Unknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 474-Jacobs.Tyler 401 334-Fries 03 ,04,2025 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 } }____r____; I i 1 i _ } combination):Haeight rating more than 10,000 pounds(example:truck or truck/trailer -< 1. INDICATE NORTH p1 1 1 I 1 N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i I I 1 1 - } (example:shuttle or charter bus):or I I I 1 1 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O `----------i r 1 i 1 iL r Iaadon° - } } } transporting employees in the course of their employment(example:employee X qua transporter-usually a van type vehicle or passenger car):or w } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or O L t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D - placarding(example:placards will be displayed on the vehicle). XI m f - -1 r, t CARRIER NAME Z ADDRESS 0 w n tembemLn CITY/STATE/ZIP g —A1P�SW'! - i. 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 . -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 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 Black Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE