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HomeMy WebLinkAbout2025-00038398 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 1011011000001111�III11111000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0038564 9 u1 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U1 3 U2 1 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) N B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00038398 VENT ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I RT20 RELATED ®Y 0 N 06 16 2025 04:59 ❑AM ❑YES ®No u1 -< Elgin PRIVATE mo /day/yr NPM FLOW CONDITION m FT!MI N E S W HIGHLAND WOODS BLVD COUNTY PROPERTY ❑Y N N DOORING ❑Y #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑ucv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n T TOWED U1 Q NAME(LAST,FIRST,M) g mo /1 9 8 4 Ford Mustang 2024 00-NONE „ , DUE TOCRASH ® ID 13-UNDER CARRIAGE FIRE 0 N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 N U2 0 m M 2 4 ❑Y NSYSNEM❑UNK VINEH. 0 AET CRASH 0 99-UUNKNOWN THER 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL a I,.4 COM VEH 0 N 1 0 ~ ELGIN I N I L 60124 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut Z EP56741 IL 2025 REAR TELEPHONE IL D 0 3FMTK3SU7RMA26559 Allstate ❑Y ®N U2 1 - in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 811843162 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER /2 0 0 7 Ford Fusion 2012 00-NONE O" z j--O DUE TO CRASH rg ❑ 2 x o 13-UNDER CARRIAGE j ©I? 2 FIRE ❑ N U2 C PS F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X ❑Y NJ8 N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF O Oistraetlonvalue 9 U1 0 1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��IJ 5 it 4 COM VEH ❑ N CO FIRST CONTACT 2 7_ _,L_5 •If Yes.See Sidebar = PINGREE GROVE IL 60140 B 1 0 DY52105 IL 2026 REAR IL D 0 3FAHPOHA5CR113996 State Farm ❑Y N N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Pingree Grove Fire 99 9 Parker.Chad.G. 3364304-SFP-13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (WI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 6 04 / D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 N 11 4 06,16 /2025 04 59 ®AM in a Work Zone? NI N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,i v 2 ❑ 2 28 O6,16 ,2025 04 59 ®pM El Construction R O ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 8 3 ❑AM 0 Maintenance U2 a 1 ® 11 4 ARREST NAME Nagalla.Vamsi. K. 11-901-A S1542-000304 06,16/2025 05 06 N pM• • El SLMT IV CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El AM t 2 ❑ 1 1 4 ARREST NAME Nagalla.Vamsi. K. 11-601 S1542-000303 06/16 /2025 05 49 N PM 0 Unknown work zone type U1 25 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1 542 Chafe. Ethan sot 391-Jacobucci 07 , 15/2025 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. 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 INDICATE NORTH combination):or .Z531 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or C) _A. _.� _ } dgemned toloaeesl5 or in hecoer rpassense of their rers tl employmentop example:etractc carrier I ° transportingtransportr-usually a van type vehicle or passen car):or C} }L --------- �`: 4. Is used or desi nated to trans rt between 9 and 15 ssen rs,including[he dryer,: ,: : _ ` } } } for direct compensation(examp large van used for specific purpose):or L L--_-a-...� „ I2... A.:.,...,4Lilot t i. i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires to O D picarding(example:placards will be displayed on the vehicle). XI 1:1:::1Z-.......------i::-...--.......H:t...t L i. r. ..... ..... CARRIER NAME Z i. ADDRESS 'n C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate El Intrastate 0 . ; ❑ Not in Comm./Govt. 0 Not in Comm./Other � "Y""1 USDOT NO. ILCC NO. m XI Source of above z . own tank)? 0 Yes 0 No 0 UnknownT. 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 to 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 White Blue u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE