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HomeMy WebLinkAbout2025-00067982 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00399.947* u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 4 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TWO/ ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00067982 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y ❑N 10 17 2025 ❑AM ❑YES ®NO U1 -< GIFFORD RD Elgin06:07 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl FTlMI N E S W SPAULDING RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD DO U2 -I igI AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 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 C) T 1 0 / yr Chavalaveettil.Santha Hyundai Accent 2016 00-NONE ©, >2 �/OUETOCRASH ® ❑ 13-UNDER CARRIAGE ,a l 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 O M F 2 SYTM IN ENGAGEis-OTHER 5 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 4 COM VEH 0 Ea 1 0 H F. BARTLETT I L 60103 B 1 0 FIRST CONTACT 12 7_: __s *II Yes.See Sidebar U1 ZBB99672 IL 2025 REAR TELEPHONE IL D 0 KM HCT4AE5G UO95207 Allstate ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Chavalaveettil. Paulselacy.G. 102219578 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI p; DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 MAV 0 NOV 0 Dv CIRCLE NUMBER(S) U1 !2 0 0 2 Ford F550 2009 00-NONE i-j t2--_, DUE TO CRASH 0 ® 98 xi o y Yr 13-UNDER CARRIAGE 10 :., 2 FIRE ❑ ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 11:--4 COMVEH ❑ ® U1 W FIRST CONTACT 15 Y _, .6 •If Yes.See Sidebar m ELGIN IL 60120 0 1 0 168430F IL 2026 I 4 N Z IL D 0 1 FDAF56R19EA49421 StateFarm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Martinez.Jose. L. G903897F1613 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS))TELEPHONE) (EMS) (HOSPITAL) :A / / UI 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 4 Martinez.Jose. L. BC1500 brush chipper 10,17 ,2025 06 07 0 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 2 0 18 SHERIDAN ST ELGIN IL 60123 2 99 10,17 ,2025 06 08 PM ® • 0 Construction >E " O 3 ❑AM ❑Maintenance U2 -a, ARREST NAME Chavalaveettil.Santha 11-901-A 1530000506 10/17/2025 06 16 Igi PM SLMT o u ® 11 4 ISICITATIONS ISSUED 0 PENDINGUtility o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 t 2 El ARREST NAME Chavalaveettil.Santha 3-707 1530000507 10,17 /2025 06 32 ®PM 0 Unknown work zone type U1 15 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15 1530-Soto.Oscar 401 11 ,04,2025 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 tO50A A ADDITIONAL UNITS FORMS. r ----r••--, , ® - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z II 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` -' -' r INDICATE NORTH combination):or -I Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C j. - } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w C i. }-----}----; �. I. } } drive 4. Is used or designated to transport between 9 and 15 passengers,including the r, for duect co nsata (example:I van used for cl rt L .l. gyp. _ . _ 5. Is anyveh'x�leusedtotansportanhazardousmaterial(HAZ(NAe)tha requires m Y �\ i placarding(example:placards will be displayed on the vehicle). . ' ." D CARRIER NAME Z Spaulding?Rd - i. ADDRESS0 , - CITY/STATE/ZIP MOTOR CARR.ID ❑ Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other 00 Y Gifford?Rd USDOT NO. ILCC NO. C 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 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 White White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE El NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE