HomeMy WebLinkAbout2025-00081947 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004097O88
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00081947 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m
BOWES RD El in02:33
® ❑ RELATED ®Y 0 N 12 30 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W UMBDENSTOCK RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 co
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FROf�tr TOWED U1 Q
Gonsalves.Sharen.V. Toyota Camry 2010 00-NONE Q 12 1 DUE TO CRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
O 2 DISTRACTED 0 0 U2 0 m
F 2 5 ❑Y ®SNEM❑ IN ENGAGED UNK VEH. O 99 AT CRASH 0 -UUNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, i�6 �i COM VEH 0 j$J 1 0
Buffalo Grove IL 60089 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.SeeSidebar U1
ZS217556 IL 2026 REAR
TELEPHONE
IL D 0 4T1 BF3EKOAU094051 Allstate Insurance ❑v IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Gonsalves.Vijay 811922665 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r use 0 KKv 0 Dv CIRCLE NUMBER(S) U1
1 9 yr 6 Dodge Ram 1500(pickup) 2019 00-NONE 11 12 DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE FIRE ❑ ® U2C
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M 2 4
❑Y NJi N ❑UNK VEH. AT CRASH 99-UNKNOWN *DistractionValue 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i 6 l!-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y��_,__5 •Iryes.See Sidebar C
Z SOUTH ELGIN I L 60177 0 1 0 2774452B I L 2025 I Si)0
M
IL D 0 1 C6SRFFT3KN893359 Foremost Insurance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same A7994396150 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
1 u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 12,30 /2025 02 33 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n
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2 ❑ 2 99 + / ❑PM- ❑Construction *
1 •
Z3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
oD El 11 1 ARREST NAME Gonsalves.Sharen.V. 11-901 1562000064 r r El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
AM45
Tr 2 ❑ 1 1 ❑❑PM ❑Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
1562 Amador.Aidan 702 , / ❑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
A 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} r
i- --_. -_--; INDICATE NORTH combination):or
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale I - (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
IICIMIDDIM L L.__-a__-_� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
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L L__._a____. — — — t l. I. 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
�f~ oa placarding(example:placards will be displayed on the vehicle). XI
S pr i. i.
_ CARRIER NAME ADDRESS Z
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CITY/STATE/ZIP'"" -I.
MOTOR CARR.ID 0 Interstate 0 Intrastate
i.
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. 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
Silver Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG.—CARGO BODY TYPE_LOAD TYPE