HomeMy WebLinkAbout2025-00050701 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4G3913116_
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00050701 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m
SUMMIT ST El 12:27
® ❑ RELATED ®Y ❑N 08 05 2025 12,— ❑YES ®No U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W HIAWATHADR COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR NI SLOW 1 0)
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGED AREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) p mo
/2 0 0 0 Toyota Prius 2007 00-NONE ,, 12 , DUE TO CRASH ® ❑ E
13-UNDER CARRIAGE FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ]$I U2 0 m
F 2 4 SYTM❑Y ®SNE❑LINK VEH. 0 ATCRASHH D 0 99-U 15-UNKNOWN THER 9 76•TOP4 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ !!--5--(..--
I 6 jl COM VEH ❑ j$J 1 n
F. FIRST CONTACT 3 7 _�_-_;_-5 *I(Yes,See Sidebar U1 0
Z HOFFMAN ESTATES IL 60192 0 1 0 FC55773 IL 2026 "s
TELEPHONE
IL D 0 JTDKB20U173292512 NIA ❑Y ❑N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 KAMALOV.AZIRET NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
t RESPONDER eu
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 KCV 0 DV
Yr
/1 9 6 7 Nissan Pathfinder 2007 00-NONE ,�_"i Qj O DUE TO CRASH ❑ 2
13-UNDER CARRIAGE FIRE ❑ ® U2C
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M 2 4 SYSTEM IN 0 ENGAGED 1 15-OTHER 9 1,6-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 ii, COM VEH ❑ ® U1 CO
FIRST CONTACT I 7�. -5 *If Yes.See Sidebar
= ELGIN IL 60120 0 1 0 AQ51061 IL 2026REAR 0
IL D 0 5N1AR18W67C611129 Amigo Insurance ❑y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X
99 9 Same I LP2757162 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
ui =
iUN1T) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 06 /
LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
Z
N 1 ® 11 4 08/05 /2025 12 27 ®AM 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
o"
2 0 06 99 / / ❑PM ❑Construction >E
Z 3 0 Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o u 1 ® 11 4 ARREST NAME Dzhaparova. Umutai 11-801 S1563-000045 / / ElPM SLMT
•
ljg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility
t 2 El ARREST NAME Dzhaparova. Umutai 3-707 S1563-000046 08/05 /2025 01 30 0 PM 0 Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑y 35
1563-Rodriguez.Carlos 202 09 / 16/2025 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 truck trailer -<
i- ;.--__r-_--; ( INDICATE NORTH combination):or —1
p1
•
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i., Not To Scale J N. r _ (example:shuttle or charter bus):or X
Z A ' 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
1 ' i-- } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
i. i. --}----; '~^ I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
.,._ for direct compensation(example:large van used for specific purpose):or
,,
L L____a____. Ivy., '` _ t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
- —1
Summit?St e ` CARRIER NAME Z
1 r _ ADDRESS 0
789?Summit'St 0Mobit70aa?$tation CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
Hia i7or
;____Y____1 USDOT NO. ILCC NO. m
XI
Source of above Z
. m
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
Tan Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE