HomeMy WebLinkAbout2025-00038901 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011000 011 * 11110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00366210
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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 14
VEHICLE/PROPERTY ®OVER 31,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00038901 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 06 18 2025 ❑AM ❑YES ®NO U1 -<
ST CHARLES ST Elgin04:14
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROf4r TOWED U1 Q
NAME(LAST,FIRST,M) Niemaszyk. Hermelinda mo
H undai Tucson 201 0 00-NONE DUE TO CRASH ® 0
0 6 ! / yr y 1t. 12
13-UNDER CARRIAGE 10l 1: 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 2 m
F 2 SYTM IN ENGAGETHER
6 ❑Y ®SNE❑UNK VEH. O AT CRASH O 99-Uis-UNKNOWN 9 16-TOPO ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH 0 0 1 n
F. FIRST CONTACT 3 7 _—--I-_5 *II Yes.See Sidebar U1 0
Z SOUTH ELGIN IL 60177 0 1 0 1006968 IL 2025 Ia, ;
TELEPHONE
IL D KM8JU3AC9AU032342 American Family connect p ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Elgin Fire Same BX13322886 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y El 2 c
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑l uv 0 Ncv ❑Dv
'1 9 8 1 Nissan Leaf 2022 00-NONE 0. QI'-0 DUE TO CRASH rg ❑ 2 73
0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
POINT OF 8 i1�.-4 COM VEH 0 ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •IfYes,See Sidebar
Z WEST DUNDEE IL 60118 0 1 0 FF23326 IL 2025 I C
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IL D 1 N4AZ1 CV6NC551987 Progressive ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 932627500 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (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 ❑Y U2 Z
N 1 ® 11 1 06,18 ,2025 04 14 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 2 99 06,18 ,2025 04 15 mi pM ElConstruction >E
R 1 O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS TIME 5
3 ❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Niemaszyk. Hermelinda 11-901-A 1552000103 06,18 l2025 04 21 Igi pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
r 2 El ARREST NAME 06/18 ,2025 04 43 ®PM 0 Unknown work zone type 0 AM
U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
1552-Thompson.Ahmad Rashad 401 07 , 15,2025 01 30 ®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 truckrtrailer -<
i- ----_r_-_-; INDICATE NORTH combination):or
p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
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< <---- -•-•� transportinggemployeened to s 5 or fewer inhecourseeo their rs employ nt example:employee a contract ner X
■ i I.
r } transporter-usually a van type vehicle or passenger car):or w
I t ,t. earttet C
__ __ ;' 1. } } . •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (1)-lk for direct compensation(example:large van used for specific purpose):or O
__ __ #[rip' I _ t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I Unit 1 . . . . placarding(example:placards will be displayed on the vehicle). XI
' - CARRIER NAME —1
Z
0
' ADDRESS
D
Not To Scale CITY/STATE/ZIP n
_ i. i. i. i. MOTOR CARR.ID 0 Interstate El Intrastate
etlM7Chvkc?et C)
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
Silver Black
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE