HomeMy WebLinkAbout2025-00060604 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00060804 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ❑Y ®N 09 16 2025 ®AM ❑YES ®NO U1 -<
S RANDALL RD Elgin09:07
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W RT20 EB COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Co
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
0 6 !
yr 13-UNDER CARRIAGE i FIRE 0
IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 5 M
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER O9 16.70P 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL B 4 COM VEH ❑ 0 1 0
F. FIRST CONTACT 10 7 ;—, _5 *Irves.See Sidebar U1
Z Crystal Lake IL 60014 0 1 0 FG53798 IL 2026 REAR
TELEPHONE
IL D JTHL9JBH2L2026151 Sate Farm ❑Y J N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 1132727SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 73
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 NCv 0 Dv
!1 9 8 0 Lexus RX330 2004 00-NONE 11-.. 12 m DUETO CRASH ❑ 2 x
o 13-UNDER CARRIAGE I FIRE ❑ ® U2
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F 2 4 SYSTEM IN ENGAGED 15-OTHER 9,16-TOPO3 * 0 X
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN Oistraellon Value
POINT OF 8 i1�1" 4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 1 Y _5 •• •It Yes,See Sidebar
— Prospect Heights IL 60070 0 1 0 CJ62463 IL 2026 I 0
Z
IL D 2T2HA31 U04CO24809 First Chicago ❑Y ®N RDEF .73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Janostak, Leos ILS1179944-00 BAC
E
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)
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/ U1 1 D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 1 09,16 l2025 09 07 ®❑PM in a Work Zone? NJ DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
o", T
2 ❑ 20 2 1 , 0 PM ❑Construction *
Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
oEl 11 1 ARREST NAME Pham,Gia, P. 11-709-A 298001307 / ! ❑PM SLMT
S' N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
r 2 ❑ 45
ARREST NAME AM
T 1 1 ❑❑PM 0 Unknown work zone type U1
2 2 3 El ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
298-Lopez, Mirko 801 10 , 14,2025 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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
l 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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3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
r - } } } transporting employees In the course of their employment(example:employee X
- Nor'lb Srais i I transporter-usually a van type vehicle or passenger car):or w
L L.___a____.IIC
4. Is used ordesi natedtotrans rtbetween9and15 ssen rs,includingthedriver,
I I t } } for direct compensation(example:large van used for specific purpose):or
L L--_-a — I R01037� — - t i i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). XI
E CARRIER NAME
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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
Black Blue.Light
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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE