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HomeMy WebLinkAbout2025-00034349 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 1111111111111111 11111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4632-48845' u, 9 U21 2 4 1 U1 5 U2 1 U, 1 1_12 1 U, 1 U2 1 5 10 U1 4 U211 *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 ❑5501-51,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ❑AMENDED ElB Injury and/or Tow Due To Crash YR 2025I 2025-00034349 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7 TOASTMASTER DR Elgin 09:18 ® ❑ RELATED t3I Y 0 N 05 29 2025 ❑AM ❑YES ®NO U1 -< g PRIVATE mo /day/yr ®PM FLOW CONDITION ITT _ FT N E S W CONGDON AVE COUNTY PROPERTY El EN DOORING ❑y #OF MOTOR El SLOW 1 (n ❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI 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 0 O T TOWED U1 Negi.Gabar.S. 0 1 / yr 13-UNDER CARRIAGE ©,I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 in M 2 4 SYTM❑Y ®S NE DUNK VEH. 0 AT CRASH 0 99-UNK 15- NOWN THER9 16•TOP 3 `Distraction Value 9 ALGN 2 T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ii_6 1, 4 COM VEH 0 E! 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1 Z S326915 IL 2025 REAR TELEPHONE IL D 0 SFNRL5H69BB015573 Encompass ❑Y ®N U2 I' .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 2017469589 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 eu m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0!My 0 I<Cv 0 DV /1 9 6 7 O Toyota Prius 2017 00-NONE ,�_' t2 "_, DUE TO CRASH ❑ Ig► 25 0 13-UNDER CARRIAGE 6 I 2 FIRE ID ® U2 C c ® M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 U1 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI . ,-4 COM VEH ❑ ® CO FIRST CONTACT 1 O Y _,_.5 •If Yes.See Sidebar — Hanover Park IL 60133 0 1 0 DN36821 IL 2025 I 0 C Z IL D 0 JTDKARFU4H3035252 Liberty Mutual ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same ASE665067247475 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 02 / :A / / UI 1 D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 05/29 /2025 09 18 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 0 06 99 / / 0 PM ❑Construction * N 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 -, ® 11 1 ARREST NAME Negi.Gabar.S. 11-801-A 1530000392 , / El PM SLMT igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 8 N ❑AM 30 t 2 ElARREST NAME Negi.Gabar.S. 11-402-A 1530000391 , / ❑pM 0 Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1530-Soto.Oscar 201 07 ,01 ,2025 09 00 ❑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. Toastmaster?Dr . A CMV is defined as any motor vehicle used to transport passengers or property and: Z I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - i- ;.---.r----; INDICATE NORTH combination):or p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i Unit 2 - (example:shuttle or charter bus):or I- :- -J.;-•--; i;;!� Sl{A - } } } transporting employeesned to Inthe course passengers or fewer thir emplod yment example:employeerier X - y transporter-usually a van type vehicle or passenger car):or co L L____a }' `~�� } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, .. ;. ` for direct compensation(example:large van used for specific purpose):or L ;----_;----; Congdon?Ave ,, - t i. i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). 1 - . l --I- CARRIER NAME Z ADDRESS 0 w 4, - CITY/STATE/ZIP 0 N i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate II _ ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 -Y- -_ Not To Scale I ` ` USDOT NO. ILCC NO. C m XI Source of above z . 0 Yes J No ❑ Unknown A 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Gray 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