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HomeMy WebLinkAbout2025-00075553 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 0110 1111 10 N��H DVI1lI100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV *X004043114* u, 1 U21 2 4 2 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 4 14 U, 1 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 ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00075553 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 11 24 2025 ❑AM ❑YES ®NO U1 -< W CHICAGO ST Elgin07:22 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W S EDISON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I !g! AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q Ka umov. Komi! 0 1 / yr . Q 13-UNDER CARRIAGE �0 EN E i : 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m M 2 SY4 ❑Y ®SNE El UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL B 4 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1 V Z Aurora IL 60503 0 1 0 ED82694 IL 2025 REAR TELEPHONE IL D JTDKAMFU3N3159334 State Farm ❑Y Il N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co 99 9 Same 3493395SFP13 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ElN 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m v 0 Ncv 0 Dv !1 9 yr 8 Dodge Ram 1500(pickup) 2023 00-NONE 0.,. z j--_, DUE TO CRASH ❑ 2 73 O 13-UNDER CARRIAGE 9 I ©). 2 FIRE ❑ ® U2 C Ti M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s FIRST CONTACT 11 7-il 6 I LC_1:, 4 5 CO•If Yes.M VEH See Sidebar❑ NI U1 W Z SOUTH ELGIN IL 60177 0 1 0 LVL3-BH IL 2026 REAR C 0 N n IL D 1 C6SRFJT9PN591878 State Farm' ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 Same 3016638SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 co 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 ,24 /2025 07 22 ®PM AM in a Work Zone? ®N DIRP > 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 23 99 , ! 0 PM 0 Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 - U2 a, ARREST NAME Kayumov, Komi! 11-901-A 1535000247 / ! ❑❑PM ❑Maintenance SLMT® 1 1 1 • ❑CITATIONS ISSUED PENDING MT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit y 0 AM r 2 ElARREST NAME hi24 ,2025 07 22 ®PM ElUnknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1535-Solis, Laura 601 12 ,23,2025 01 30 ❑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 -< i- }---.r-_--; — _ combination):or LN:r: INDICATE NORTH1BY ARROW2 Is used or designed to transport more than 15 passengers including the driverC} } r r ,. (example:shuttle or charter bus):or Itransporting employeened to sl5 or fewer in the courses o rhea emrs and ployment example:employeener transporter-usually a van type vehicle or passenger car):or 0L L.___a__ L I. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including w} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L ' ___.: unit1 < < < 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires '0 l - placarding(example:placards will be displayed on the vehicle). XI » D , .11 CARRIER NAME -� I ADDRESS 'n i T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate El Intrastate Z I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. rn XI Source of above z . -I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 VIM 1 m co 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 Silver Blue 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE