HomeMy WebLinkAbout2025-00072607 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III H
II II
UHI II II II )III IIIIII IIIIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X�O24631
u, 1 U21 2 4 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 5 11 U1 11 U211 *P 0119
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-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00072607 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
SPARTAN DR El In 05:32
® ❑ RELATED ®Y 0 N 11 09 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W S RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
FOR DAMAGED AREA(S) FRONT TOWED U1 O
Etemadi. Parvaneh 1 2 /
yr 13-UNDER CARRIAGE .I ! 2�. FIRE ❑
IE
10
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 1 r<rl
F 2 4 SY❑Y ®SNE❑UNK VEH. 0 ATCRASHD15-OTHER
0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i 4 COM VEH 0 j$J 4 0
f. FIRST CONTACT 11 7_:—____5 *Ilsees.See Sidebar U1
Z Gilberts IL 60136 0 1 0 DH35381 IL 2026 REAR
TELEPHONE
IL D 0 KM H LR4AFXN U335761 State Farm ❑v Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1015537-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0
9 9 4 Infiniti Q70 2016 00-NONE 1O t2 (,-2 FIRE DUE o CRASH ® U2 2 C
o 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s- 1. 6 j', 4 COM VEH ❑ ® U1 W
F,,, FIRST CONTACT 5 7�'—_,SOS •byes,See Sidebar
ELGIN I L 60120 0 1 0 AAA94-CC I L 2026REAR
C
M
IL C 7 JN8CS1 MW8GM751866 Country Financial ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Hernandez. Patricia PO10476738 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT? (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL)
2 4 09 /
4 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,91 /025 05 32 ®AM in a Work Zone? ®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 ,,
o"
2 0 28 18 / / ❑PM• ❑Construction *
Z3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 8
o ® 11 1 ARREST NAME Etemadi. Parvaneh 11-601 S1542-000533 / / El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
0 AM
T 2 El ARREST NAME 1 1/9/ /025 05 45 ®PM ❑Unknown work zone type U1 3O
2 2 3 ID
ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1542-Chase. Ethan 702 12 / 16/2025 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•---, , \\\11
1 A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1 gmore than pound (example:truck or truckrtratler
1. Has a weight ratio 10,000 5
` ` --I- -' 1 INDICATE NORTHcomWnatlon)or
` BY ARROW2 Is used or designed to transport more than 15 passengers including the driverCt N - } (example:shuttle or charter bus):or t Nor To Scare 3. Isdesgnedtocarry15orfewer passengersandoperated by a contract career I O
— - - } } } transporting employees In the course of their employment(example:employee X
t transporter-usually a van Type vehicle or passenger car).or co
L L.___a__ 1 •} 4. Is used ordesi nated to trans rt between 9 and 15passengers,includingthedriver,
` ! } for direct compensation(example:large van used for speific purose):or 0
L .I. I - 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
21.
—1
CARRIER NAME Z
' ADDRESS O
1 ♦tom cn
C)
CITY/STATE/ZIP g
. - MOTOR CARR.ID 0 Interstate 0 Intrastate
® ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
.----Y- --+
111 USDOT NO. ILCC NO. C
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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
Red White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE