HomeMy WebLinkAbout2025-00030543 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00361D147
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00030543 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
GANSETT PKWY Elgin09:41
® ❑ RELATED ®Y 0 N 05 14 2025 ®AM ❑YES ®No u1
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT N E S W WINDING HILL DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI 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 C)
1 2 /
yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0U2 0 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 �i COM VEH ❑ Ea 1 0
m ~ ELGIN I L 60124 0 1 0 FIRST CONTACT 11 7_:— __5 *lI yes.See Sidebar U1
Z FE62396 IL 2026 REAR
TELEPHONE
IL D JTDKB20U153026162 Progressive ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 996849548 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 NAV 0 NOV 0 Dv
2 0 0 1 Honda Accord 2006 00-NONE 11_"I Qr O DUE TO CRASH 0 ❑ 2 x
o 13-UNDER CARRIAGE 10( ) 2 FIRE ❑ El U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 Il, COM VEH D ® U1 CO
FIRST CONTACT 1 Y _,__5 •(ryes,See Sidebar
= ELGINREAR C
n IL 60124 0 1 0 C227165 IL 2025
IL D 1 HGCM66546A032994 State Farm ❑y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Ulankiewicz.Alexis 7388291-F27-13C BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (0081 (SEX) {SAPT) (AIR) (INJ) (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 0 Y U2 Z
N 1 ® 11 1 05,14 ,2025 09 41 Am
in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
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2 ❑ 2 99 1 1 ❑PM• ❑Construction *
Z 3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Patel, Dhruv. P. 11-901-A 327003154 / ! El PM SLMT
01
CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
o N
30
r 2 ❑ ARREST NAMEAM
T 1 / ❑❑PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑y 30
327-Hromadka,Scott 801 275-Engelke 06 ,24,2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }__-_r_-_-; combination):or
INDICATE NORTH 5311
:BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} A i
} } } transporting employee In the course of their employment(example:employee X
ID 41 J I
transporter-usually a van type vehicle or passenger car):orco
LL 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or o
L L____a.....: - - -ipt. l I 1 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
1 r' L %. .. ... ....
CARRIER NAME Z
ADDRESS 'n
th
[ NOtTo Ie CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __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
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
Gold Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE