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HomeMy WebLinkAbout2025-00035680 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Dt 2 Sheets IC HHH 11 IIIIII UHI UU I lU IIII1111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003846102* u, 1 U21 3 4 1 U1 4 U2 1 U, 1 U2 1 1.11 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash El AMENDED YR 202512025-00035680 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mHIGGINS RD Elgin ® ❑ RELATED ❑Y ®N 06 04 2025 12,— ❑YES ElPRIVATE NO U1 mo /day/yr 04:40 ®PM FLOW CONDITION m I0 ® © COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Cl) !MI N E S Galvin Dr WITH VEHICLESOT, INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n O 3 / BMW M5 ZO13 00-NONE 11 OI_1 OUETOCRASH ® ❑ E 13-UNDER CARRIAGE 1a i , 2 FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El U2 2 m F 2 SY5 ❑Y ®SNEM UNK VEH. 0 AT CRASH 0 IN ENGAGED15-OTHER 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�6 4 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7 ;—, _5 *Irves.SeeSidebar U1 Z Chiacgo IL 60614 0 1 0 M N 2295 IL 2026 REAR TELEPHONE IL D SUXZV4C55DOB16115 CHUBB INDEMNITY El ®N U2 I''I 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Elgin Fire 99 9 Same 1300602005 1 1— "6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y El 2 0 Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NAV 0 KCV ❑Dv � 1 9 9 8 Chevrolet Silverado 2019 00-NONE +i_-I 12--_, DUE TO CRASH ❑ !g► 24 o yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C Po F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 0 Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI 6 1',_4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 Y__{_ -5 •IfYes,SeeSidebar ~ 60110 0 1 0 312131D IL 2025 REAR 0 CC/) M IL D 1 GC1 KREG5KF263724 Auto Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 JDK Services INC 375121601 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 06,04 /2025 04 40 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 0 03 99 1 ) 0 PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Nakamoto,Tessa,G. 11-601 W1535-000200 / r El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM r 2 El ARREST NAME 06104 12025 04 40 0 PM El Unknown work zone type U1 3O n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1535-Solis, Laura 901 391-Jacobucci 1 1 ❑❑pM Workers present? ®N U2 30 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- i•--__r-_--; Q N= } combination):or INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C Not To Scale I ,- (example:shuttle or charter bus):or . r r tj I I I 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O } } } transporting employees In the course�of their empbymaeent(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L i — — — — — L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). m 0 2:.__ 1 p l ,Nyym, CARRIER NAME I I I ADDRESS 0 D n CITY/STATE/ZIP 0 � L r it - MOTOR CARR.ID 0 Interstate ElIntrastate I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other i— ------1 - USDOT NO. ILCC NO. rn XI Source of above z . GVWR/GCWR m 0 <10,0oo 0 10,000-26,000 ❑ >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No g If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 E 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 VIM 1 m to LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray White 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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE