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HomeMy WebLinkAbout2025-00066363 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 0011 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003989a3 u, 1 U21 2 4 1 U1 3 U2 1 U1 1 U2 1 U1 1 U2 1 4 10 U, 4 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (8:1B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00066363 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 ® ❑ RELATED ' V 0 N 10 09 2025 DAM ❑YES ®NO U1 -< SOUTH ST Elgin11:23 g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT N E S W S EDISON AVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR IR SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FROM TOWED U1 Q Kilgore, David.J. 0 7 / yr 13-UNDER CARRIAGE © ! 2FIRE ❑ al E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m M 2 SY 15-OTHER 5 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�S �i COM VEH 0 j$J 1 0 ELGIN IL 60123 0 1 0 FIRST CONTACT 11 7_; __5 *llYes.SeeSidebar U1 ZFQ47527 IL 2025 REAR TELEPHONE IL D 0 1 FMCU9GX8DUD50270 Geico ❑v ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 6218496187 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ❑ N 2 0 m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ uv 0 NOV ❑DV !2 0 0 4 Honda CRV 2014 00-NONE 1,_' t2 0 DUE TO CRASH rg ❑ 2 x o 13-UNDER CARRIAGE I FIRE ❑ ® U2 c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,,6.TOPO3 * X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistraellon Value 0 POINT OF 8 i1 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 6 Im FIRST CONTACT 2 7�� _,-`-�*((Yes,See Sidebar Sleepy Hollow IL 60118 0 1 0 EZ57229 IL 2026 I 0 C Z IL D 0 2HKRM4H39EH724832 Farmers ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 540173129 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 m ##OCCS y 71 / / U1 1 D / / 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 10,09 l2025 11 23 ®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 0 2 ❑ 23 15 ( ) ❑PM ❑Construction * Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Kilgore, David,J. 11-1204-B 471-000566 / ! ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑ 30 Utility T 2 ❑ ARREST NAME AM 7 1 r ❑❑PM El Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 471-Evans, Lakysha 701 363-Vartanian 11 , 18,2025 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 -< 0 INDICATE NORTH p0 1 BY ARROW combination):or 2 Is used or designed to transport more than 15 passengers including the driver } C I - } (example:shuttle or charter bus):or X 3. Is designed to carry15 or fewer passengers and operated a contract carrier O I- <.__-A-.-.� sow? ltk., f k i. } r } transporting employee in the course of their employment(example:employee X / transporter-usually a van Type vehicle or passenger car):or C L }-----}----I. � - • I I 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)i , --:ITT: for direct compensation(example:large van used for specific purpose):or o aiiiL L___-a..... �— — t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires u placarding(example:placards will be displayed on the vehicle). ,Zmt —43 l _ CARRIER NAME Z l 4 ADDRESS 0 C) i CITY/STATE/ZIP g Not To Scale ( MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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'; 0 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 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. 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