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HomeMy WebLinkAbout2025-00036155 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 0 liii fl 0 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003846057* u, 1 U21 3 4 1 U1 2 U2 1 U1 1 1_12 1 U, 1 U2 1 1 10 u1 4 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00036155 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m ® ❑ RELATED ®Y 0 N 06 06 2025 ❑AM ❑YES ®NO U1 -< LAMBERT LN Elgin04:24 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W RT20 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ 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 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONr TOWED U1 Q Pavliuk. NAME(LAST,FIRST,M) Stepan mo /1 9 9 9 Volvo Truck 202Z -NONE it. 12 -_, DUE TO CRASH 0 EN 13-UNDER CARRIAGE 10l 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY4 0 Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN x r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $• i� B � COM VEH ® 0 1 n .I2 Z Schaumburg I L 60193 0 1 0 P1136118 IL 2025 FIRST CONTACT 5 7 ;MAP _O =II Yes.See Sidebar Ut c TELEPHONE IL A 7 4V4NC9EH2NN300296 Highlander Specialty ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 2b5204af99f34fd1 adf0 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 9 20 c x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 N V ❑Dv yr ' 2, _ C ... 13-UNDER CARRIAGE ©)! FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0 s i1 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1i COM VEH 0 ® U1 to FIRST CONTACT 11 7. _5 •If Yes.See Sidebar n ELGIN IL 60120 0 1 0 RICHD IL 2025 ARC 0 IL D 0 2HGFB2F83DH512223 Allstate ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 975727050 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER® 9 U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 06/06 l2025 04 24 ®FM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 0 06 99 ) 1 0 PM ❑Construction * Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Pavliuk.Stepan 11-708 1531000064 / ! El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM r 2 ❑ ARREST NAME 06 r 06 12025 05 00 ®PM El Unknown work zone type U1 45 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1531—Sch'c mbach.Jack 401 391-Jacobucci 07 1 08,2025 01 30 ®pM Workers present? ®N U2 45 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 J I L. 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_-__; Leke?St INDICATE NORTH combination):or p1 - - - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X - -----------; q - y } } } transporting empined to oyees Inthe course of 5 or fewer he r emplrs oyment(example:employee a contract rier X . transporter-usually a van type vehicle or passenger car): r co L L.___a____.I - - - 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including- - N • } } for direct compensation(example:large van used for cific ur mdudi the driver, Pe ( P 9 Pe purpose):or L L____a____. �., t l. I. I _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires Iplacarding(example:placards will be displayed on the vehicle). ,Zmt Ij_} Unit 1 CARRIER NAME Z Not To Scale Ii. i. i. ADDRESS 0 Lai > CITY/STATE/ZIP I 0 _ MOTOR CARR.ID Interstate Intrastate I I T I I0 Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. m I xi Source of above z . 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 ®No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White Brown 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE