HomeMy WebLinkAbout2025-00056474 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003943355
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00056474 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
VILLA ST Elgin04:51
® ❑ RELATED ❑Y ®N 08 28 2025 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W SADLER AVE COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR El SLOW 1 (n
❑ Cook HIT ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 Nuv 0 r:cv 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROt4r TOWED U1 Q
NAME(LAST,FIRST,M) WANGPHONGSAWASD.VONGSATORN mo yr 1 9 9 2 Nissan Altima 2017 00-NONE „ O , OUETOCRASH ❑ EN
13-UNDER CARRIAGE 1a i , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDTHER 0 0 U2 2 m
F 2 SYTM 5 ❑Y ®$NE❑UNK VEH. O ATCRASHD 0 15-99-UUNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_:il 4_5 *Irves.See Sidebar U1 COM VEH El Ea 1 0
F. FIRST CONTACT 12 7 ,_
Z CHICAGO IL 60654 0 1 0 BM64125 IL 2026 is
TELEPHONE
IL D 0 1 N4AL3AP8HC477042 PROGRESSIVE ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 990738989 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
IR DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 Dv
$ 1 9$0 Volkswagen Passat 2012 00-NONE ,i_j 12..-_, DUETOCRASH ❑ 21 2 x
o 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C
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M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3
❑Y (gi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI all,._ COM VEH ❑ ® Ut CO
FIRST CONTACT 6 ..!I
•IfYes.SeeSidebar
H ELGIN IL 60120 B 1 0 EM61247 IL 2026 REAR 0 C
IL D 0 1 VWBH7A36CC109582 FALCON ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 GOMEZ. EDUARDO 0100117355 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 0 Y U2 Z
N 1 El 11 1 81 ,81 ,025 04 52 ®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 C)
o", '
2 ❑ 28 03 , , 0 PM ❑Construction >F
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
-a, ARREST NAME WANGPHONGSAWASD.VONGSATORN 11-601 1559000048 , r El PM SLMT
o N1 11 1 igiCITATIONS ISSUED 0 PENDING
® SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility
r 2 0 ARREST NAME WANGPHONGSAWASD.VONGSATORN 11-710-A 1559000049 81181 i025 05 13 ®PM El Unknown work zone type u1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 35
1559-DavE los.Yoana 8843 91 , 61 ,025 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 -<
` ` -'- ' INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
Not To Scale T`
I- I- --I--•--; transporting employeened to s inthe course 5 or fewer passengers
their emaployment nd operated
xample:employee
transporter 0 } } }
C
L •-----}----J. 1 - } } 1 • sed or des gnated to transport between 9 and passengers,15r including the driver,
co
i /�.,-.f
for direct compensation(example:large van used for specific purose):or O
__ 1 cb._ _ t i. i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
_ ADDRESS 0
O
CITY/STATE/ZIP C)
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate /�
(MY4fil.) C)
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above 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
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
Gray Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/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 ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE