HomeMy WebLinkAbout2025-00070384 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004010798
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00070384 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 10 28 2025 DAM ❑YES El NO U1
S RANDALL RD Elgin mo /day/yr 05:59 ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
00-2 FT 10 N E p W South St WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Georgiadis.Alexander. K. 0 1 /
yr 13-UNDER CARRIAGE 1a.) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 04 r n<
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r POINT OF
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 7_ 6 _5 *If Yes.See Sidebar U1
F. FIRST CONTACT 12 :il 4 0
COM VEH 0 Ea 1
Z Algonquin IL 60102 0 1 0 EK84943 IL 2026 _,
TELEPHONE
IL D 0 3LN H L2GCOAR608636 ALLSTATE ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 975472686 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 KCV 0 DV
1 9 9 7 Subaru XV Crosstrek 2.0 2019 00-NONE ,i_j t2"-_, DUETO CRASH ❑ !g 2 x
o Yr 13-UNDERCARRIAGE 10 1 2 FIRE 0 El U2 C
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F 2 4 SYSTEM IN 1 ENGAGED 1 15-OTHER 9 16•TOP 3 X
®Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
iI N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 - 5 i' 4 COM VEH ❑ ® U1 CO_
FIRST CONTACT 6 Y__{_O ._5 •If Yes.See Sidebar
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= PINGREE GROVE IL 60140 0 1 0 DY99385 IL 2026aR
IL D 0 JF2GTANC3KH294708 USAA ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Jeronimo. Dotty.T. GIC 032681060 7103 BAC
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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)
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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 ® 11 1 10,28 /2025 05 59 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 03 28 1 1 ❑PM ❑Construction
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-, ® 11 1 ARREST NAME Georgiadis.Alexander. K. 11-601 W1561-000139 1 r El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
0 AM
r 2 El ARREST NAME 101 28 12025 05 59 ®PM El Unknown work zone type U1 45
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1561 Sarovic• Mirko 801 1 , ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 03
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Tan Blue
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE