HomeMy WebLinkAbout2025-00001420 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00001420 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MCLEAN BLVD El11:54
® ❑ RELATED ®Y 0 N 01 07 2025 ®AM ❑YES N NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT l MI N E S W DAVIS RD COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 SOUSE 0 NIA/ 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
FOR DAMAGED FROM
TOWED U1 0
Shah. Hemendrakumar.V. 0 6 !
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 SYTM IN ENGAGETHER
❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-U15-ONKNOWN 016 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 .: 6-_-,4 COM VEH 0 j$J 1 O
F. FIRST CONTACT 9 :L _5
Z Skokie IL 60077 0 1 0 EG55194 IL 2025 " t ii *u yes.See Sidebar U1 8
TELEPHONE
IL D 0 2C4RC3GG2PR605320 State Farm ❑Y ®N U2 19 , m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1398800-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ uv 0 NOV ❑Dv
'1 9 4 8 Ford Escape 2020' 00-NONE „ " Oj-_, DUE TO CRASH rg ❑ 2 x
0 Yr 13-UNDER CARRIAGE FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
POINT OF 8 I 4 COM VEH ❑ N Ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:_ C
FIRST CONTACT 11 7 �. ,�_5 •Iryes.See Sidebar
— West Dundee IL 60118 0 1 0 CFB22 IL 2025 I 0 Si)
IL D 0 1 FMCU9H96LUB28955 American Family ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER I =
99 9 Same 1212-7744-16-FPPA-IL BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER 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 0 Y U2 Z
N 1 N 11 1 01 ,07 l2025 11 54 ®❑PM 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 7 C)
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o"
2 ❑ 2 06 , , 0 PM ❑Construction
1
R 3 ❑ $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Shah. Hemendrakumar.V. 11-902 S1540-000073 ! ! El PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
El AM
t 2 El ARREST NAME 01 r 07 l2025 01 10 0 PM El Unknown work zone type U1 3O
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1540-Allah. Muhammad 501 , r 0 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 INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L A Mc sn? 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee X
rter-
L ...l. I - �sedord�llnatedtotrans vehicle
rtbetween9and passenger
15r) ssen rs,indudirg[hedriver,
C
} } for direct compensation(examp large van used for specific purpose):or 0
.a (VW Davis7Rd ellitqp t i. < i. ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
X — — — .Unttt_ placarding(example:placards will be displayed on the vehicle). :0
iIt
CARRIER NAME Z
I
ADDRESS 0
D
CITY/STATE/ZIP n
I C
MOTOR CARR.ID Interstate Intrastate
ID
°
I N Not in Comm./Govt. Not in Comm./Other
Y Not To Scale 1 USDOT NO. ILCC NO.
m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
White White
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 DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE