HomeMy WebLinkAbout2025-00012318 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 101101100 lflfl VUIII IIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003737682
u, 1 U21 1 1 1 U1 2 U2 2 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
ID AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00012318 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 02 25 2025 ®AM El YES ®NO U1
GIFFORD RD Elgin 07:54
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
FT!MI N E S W GASKET DR COUNTY PROPERTY ❑Y 2�I N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRO TOWED U1 0
Thakkar. Kishori 0 2 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 M <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 M
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _
❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4 COM VEH 0 Ea 1
I .
BARTLETT I L 60103 0 1 FIRST CONTACT 12 7_:, __5 *Irves.See Sidebar Ut 0
Z DJ14640 IL 2025 REAR
TELEPHONE
IL D 4JGFF5KEONA629219 Allstate ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Parekh.Sarju. P. 811 323 941 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ID 0 N 2 C)
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 Nev ❑DV
'1 9 9 0 Kia Motors Colftpirus 2013 00-NONE 0. Q1-_1 DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
ij
M 2 5 ❑Y SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraglon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 6 --4 COM VEH ❑ ® tit CO
FIRST CONTACT 6 Ci,�=Q)OS •IfYes.SeeSidebar C
Z Carpentersville IL 60110 0 1 EK21469 IL 2025 i 0 Si)
D
IL D SXXG M4A71 DG 136910 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same I LAA-1029902-00 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
{UNIT) ISEATI IDOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 4 1 2 /
UI 3 71
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 02,25 /2025 07 54 ®❑pM 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
o"
2 ❑ 28 99 / / ❑PM ❑Construction
1
R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-, ® 11 4 ARREST NAME Thakkar. Kishori 11-601 414-1014 / / El PM SLMT
o N ElCITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
30
r 2 ARREST NAME AM
T El / / ❑❑pM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
414-Lara. Saul 401 272-Bajak 03 / 18/2025 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.
0 i 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 -
} } ' ' r f l } INDICATE NORTH combination):or -I
I_
I _ I 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} 0 - } r (example:shuttle or charter bus):or 0
I �.
` A ,� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 1 0
i. } } } transporting employees In the course of their employment(example:employee X
-1 ,1'�« transporter-usually a van type vehicle or passenger car):or 03
C
L • `r<,§xI Not To Scale l • } }- } 4. Is used or designated to transport between 9 and 1 passengers,including the driver,
for direct compensation(example:large van used fors specific purose):or
L L____a____. t i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
M
d placarding(example:placards will be displayed on the vehicle). m
0
I autos I CARRIER NAME Z
ADDRESS
0
D
, CITY/STATE/ZIPn
I I I i. i. i. i. .i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0I I T I 0 Not in Comm./Govt. o Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE