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HomeMy WebLinkAbout2025-00035437 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 01111111E111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY 44* u, 1 U21 3 4 2 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *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 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2O25-00035437 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n DUNDEE AVE Elgin ® ❑ RELATED ❑Y ®N 06 03 2025 12— ❑YES El NO U1 PRIVATE mo /day/yr 01.52 ®PM FLOW CONDITION III i20 ®!MI O E S W KI M BALL St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 2 Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUER 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q NAME(LAST,FIRST,M) GOUSKOS.AMAN DA. M. mo 0 8 / "2 0 0 1 Volkswagen Beetle 2006 00-NONE 11' © �, DUE TO CRASH El -UNDER CARRIAGE 10- r FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 4 M F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL 6 4 COM VEH 0 ZgJ 1 0 " �- LAKE BARRINGTON IL 60010 0 1 FIRST CONTACT 12 7 ; __5 *II Yes.See Sidebar U1 Z CY38173 IL 2025 E TELEPHONE IL D 0 3VWPF31Y26M311807 STATE FARM ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co GOUSKOS. PHILLIP 3074846-SFP-13 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 3 GX) g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 KCV 0 CV 1 9 9 3 Ford F150 2022 00-NONE 1t i 12--_, DUE TO CRASH ❑ ® 98 73 o yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C Ti M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 3 X ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII 6 ..,_4 COM VEH D ® Ut W FIRST CONTACT 6 Y__{_O -_5 •IfYes.SeeSidebar n ELGIN IL 60120 0 1 M237925 IL 2025 REAR Z IL D 0 1 FTEX1 EB2NKE15818 CHARTER OAK FIRE ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = CITY OF ELGIN 8109160P901 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (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 CD 11 1 06,03 i2025 01 52 ®PM AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 11 28 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING / ) ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 -a, ARREST NAME / / ❑PM ' o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 25 T 2 ❑ ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 25 374 Rizzu o. Michael 301 , ❑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 combination): more thanpounds(example:truck ortruckrtrarler _,1. Has a rating10,000 NDICATE NORTH p1 ® 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } / 1 - } (example:shuttle or charter bus):or C Not To Scab_,I �N l I 3. Is designed to carry15 or fewer I- <.__-A-.-.� / p p �z y } } } transportinggemployeeslnthecourse�o therersantl employment example�empfoyeener �/�O' 6ransportr-usually a van type vehicle or passenger car):or C L L.___a.. / II `` I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y for direct compensation(example:large van used for specific purpose):or -U I ra / t i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires mearrst - 1 placarding(example:placards will be displayed on the vehicle). XI / —I CARRIER NAME Z - ADDRESS O n CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I . ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 USDOT NO. ILCC NO. m XI Source of above z . • m 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 Blue White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE