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HomeMy WebLinkAbout2025-00031206 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I0110110000101100000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003823948 u, 1 u21 3 4 1 u, 3 U2 1 u, 1 1_12 1 u, 1 U2 1 5 15 u1 1 u2 1 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 2 VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00031206 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1 NATIONAL ST Elgin 09:22 ® ❑ RELATED coY 0 N 05 16 2025 DAM ❑YES N NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION III FT!MI N E S W RAYMOND ST COUNTY PROPERTY ❑Y N N DOORING Ely #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑V N 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 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROM TOWED U1 Q Lambropoulos.George. N. 1 0 / yr 13-UNDER CARRIAGE ©i O-O FIRE 0 N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 0 U2 2 m M 2 8 SY❑Y ❑STM NEN UNK VEH. 9 ATCRASHD 9 99-U 15-UNKNOWN THER9 76•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 I,.4 COM VEH 0 N 1 0 F. FIRST CONTACT 12 7 •-, _5 *IIYes.See Sidebar U1 Z STREAMWOOD IL 60107 A 1 0 EJ32361 IL 2025 REAR TELEPHONE IL D 0 KN MAT2MVOG P709140 State Farm ❑Y Il N U2 m IF. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 2671151-sfp-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Provena St.Joseph ❑Y El 2 ou ��, N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 K V 0 DV !1 9 8 8 Mazda CX5 2015 00-NONE „ " 12 "_, DUE TO CRASH rg ❑ 2 x o - 13-UNDER CARRIAGE FIRE ❑ N U2 M 2 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 016-TOP 3 X ❑Y ❑N N UNK VEH. AT CRASH 99-UNKNOWN *Oistrac)i n Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I .i, 4 COM VEH 0 ® Ut CO F,,, FIRST CONTACT 9 O7 j_, _s •It Yes.See Sidebar C ELGIN IL 60123 0 1 0 AT80741 IL 2025 REAR 0 Si) IL D 0 JM3KE4DY7F0549809 State Farm ❑Y N N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Elgin Fire Nunez.Janette.A. 2300816-sfp-13 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 03 / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 1 5/ r 6/ ,025 09 22 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 25 28 r r ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME Lambropoulos.George. N. 11-601 1539000193 r ! El PM SLMT o N 1 ® 11 1 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility AM 30 t 2 El ARREST NAME Lambropoulos.George. N. 3-707 1539000191 r r 0 pM ElUnknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1539-Vargas. Miguel 400 - r r ❑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 -< c ` '' -' r INDICATE NORTH combination):or .Z-1 i /Ll 1 BY ARROW 2 Is used or designed to transport more than 15 C �J passengers including the driver i \v L _Nor,,fi,s i _ i. e. ,. (example:shuttle or charter bus):n or ' I I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O namea ! • } } } transporting employees in the course of their employment(example:employee W it ,i transporter-usually a van type vehicle or passenger car):or C L -' ■ - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C. w t ' ' ' ' for direct compensation(example:large van used for specific purpose):or L l L I. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmt —1 CARRIER NAME Z C\ - ADDRESS D I rn CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above 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 Blue Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE