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HomeMy WebLinkAbout2025-00070370 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 1111 fl 100 00`111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004011181 u, 1 U21 1 1 1 U1 8 U216 U, 1 1_12 1 U, 1 U2 1 1 15 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$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 0 AMENDED YR 2025I 2025-00070370 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ❑Y ®N 10 28 2025 ❑AM ❑YES N NO U1 -< BIG TIMBER RD Elgin04:31 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m Eg50 !MI N E S State S COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ® © q Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (g)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 FOR DAMAGEDAREA(S) FROPtf TOWED U1 0 Kvasnicka.Andrew.J. 1 2 / yr 13-UNDER CARRIAGE i FIRE ❑ N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 Ea U2 2 m M 2 4 ❑Y ®Nn is-OTHER SYSTEM❑UNK VEH. ATCRASHD 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ;i�6 4 COM VEH 0 Ea 1 0 F. FIRST CONTACT 10 7 ;—, _5 *Irves.See Sidebar U1 Z Chicago Heights IL 60411 B 1 0 EL17283 IL 2025 REAR TELEPHONE IL D 0 2FMDK49CX7BA22012 NIA NY ❑N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Kvasnicka. Ryan NIA 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou N DRIVER 0 PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 ,uv 0 NCv 0 Dv !2 0 0 2 Lexus IS300 2015 00-NONE 11__' t2 0 DUE TO CRASH rg ❑ 2 o 13-UNDER CARRIAGE 10 i., 2 FIRE ID N U2 C M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN *Dist/neon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH 0 N U1 CO FIRST CONTACT 1 Y _, _5 •IfYes.See Sidebar = ELGINREAR C n IL 60123 0 1 0 FJ34887 IL 2026 IL D 0 JTHCF1 D28F5022867 State Farm ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 3559524SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (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 ❑Y U2 Z u 1 ® 11 1 10,28 ,2025 04 31 ®AM in a Work Zone? NCI N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 0 20 99 10,28 ,2025 04 38 ®PM ❑Construction * R 3 0 ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 6 z J ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Kvasnicka.Andrew.J. 3-707 S1924-000510 10,28,2025 04 40 N pM• • El SLMT l$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM r 2 El ARREST NAME Kvasnicka.Andrew.J. 11-709-A S1924-000509 10,28 ,2025 05 18 N PM 0 Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1524-Silva,Jose 501 391-Jacobucci 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 truckrtrailer -< c ` --I -' r INDICATE NORTH comWnation)or531 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C unitat - } (example:shuttle or charter bus):or C) ' A / 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O --i } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a__ - �' 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, C •:---1 } } } for direct compensation(example:large van used for speific purose):or L L____a____.I Bla7mnpitnMO, 1 t l. I 1 L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m unit?2 • • placarding(example:placards will be displayed on the vehicle). - :i —1 CARRIER NAME - ADDRESS0 N.75tate79t . D n CITY/STATE/ZIP g • Not To Scale I i.- i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate . I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other ;_...Y. ._.; - USDOT NO. ILCC NO. m XI Source of above z . 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 Black Black 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