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HomeMy WebLinkAbout2025-00032928 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 Mfl 0 00.1 IV Ili 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036318 1 u, 1 U21 1 1 1 U110 U2 1 U, 1 1_12 1 U, 1 U2 1 1 12 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00032928 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 805 PARKWAY AVE Elgin07:40 ® ❑ RELATED ❑Y ®N 05 23 2025 ❑AM ❑YES El NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 ' ❑ FT/MI NESW 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 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑MAU ❑!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 1 2 ! yr Kia Motors Coiltptima 2013 00-NONE , 12 , OUETOCRASH ❑ VI ©. 13-UNDER CARRIAGE } I! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 2 m M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE El LINK VEH. 0 AT CRASHD 0 99-UNKNOWN 016•TOP 3 ,Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 4 COM VEH 0 Ea 1 0 0 H F. HOFFMAN ESTATES IL 60192 0 1 0 FIRST CONTACT 10 7 ; _5 *uves.SeeSidabar U1 Z EN63480 IL 2026 E TELEPHONE IL D 5XXGM4A77DG175176 Kemper ❑Y ®N U2 I— i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12RA000072382 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 9 2 XI p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 NOV ❑DV !1 9 yf 8 Lexus RX350 2025 00-NONE 11_"j t2..-_, DUE TO CRASH ❑ ❑ 2 x o 13-UNDER CARRIAGE 10:i t 2 FIRE 0 El U2 C Ti F 2 4 ❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istractonValue 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 it- 6 1l, 4 COM VEH 0 El U1 CO FIRST CONTACT 1 Y , _s •(ryes,See Sidebar n ELGIN IL 60120 0 1 0 2500772 IL 2026 aR C IL D 2T2BZMCA3GC014271 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 3408160SFP3 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 05,23 ,2025 07 40 ®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) v 2 04 2 05,23 ,2025 07 40 ®pm 0 Construction * R 0 El CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ❑AM ❑Maintenance U2 -a, ARREST NAME Galogitho.John. M. 11-704-A 1512523 05,23,2025 07 47 ®pM SLMT 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING Utility o NSECTION CITATION NO. ROAD CLEARANCE TIME El 0 AM r 2 ElARREST NAME 05,23 l2025 08 00 0 PM ElUnknown work zone type U1 25 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1512-Juarez-Huichapan.Juan 200 391-Jacobucci 07 ,01 ,2025 01 30 ®PM Am Workers present? ®N U2 25 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 -< - }___-r----; combination):or INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X ' ' Not To Scale j 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O es pa g pe _ } } } transporting employees In the course of their employment(example:employee � 73 [witril 1 transporter-usually a van type vehicle or passenger car):or L }-----}----; - } } } C •4. Is used or designated to transport between 9 and 15 assen passengers,including the driver, for direct compensation(example:large van used fors cific purpose):or L i.____a____.l t i. i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)thatrequires •u !_ m -_.,ram- :,_ -- placarding(example:placards will be displayed on the vehicle). XI f - - '1 CARRIER NAME Z 805?Parkway ADDRESS > w Ave 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 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 . Form Number 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' -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 Blue 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE