HomeMy WebLinkAbout2025-00003092 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Dt 4 Sheets 01111101111 01101100 0 I I 1 11 1110
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A 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 ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00003092 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
S LIBERTY ST Elgin03:52
® ❑ RELATED ®Y 0 N 01 14 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION III
FT!MI N E S W MAY ST COUNTY PROPERTY ❑Y 21N DOORING ICIy #OF MOTOR 0 SLOW 1 (n
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FROrar
Amin.Amar. M. 1 0 /
yr 13-UNDER CARRIAGE I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
O 2 DISTRACTED 0 14 U2 0 171
M 2 SYTM IN ENGAGE8 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 0 t6-TOP 3 `Distraction Value ALGN 2
FCITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST INT OONTACT 14 Oj _F 2'4' 5 CIOMg See SidebaEH r U,Ea 1 0
Z HANOVER PARK IL 60133 0 1 0 AZ53287 IL 2025 REAR
TELEPHONE
IL D 0 19XFB2F85EE015069 Progressvie ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Amin.Zaid. M. 925288394 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 nuy 0 NCv 0 Dv
yr Ford Explorer 2013 00-NONE O, Oj'O DUE TO CRASH ❑ 2 �7
o 13-UNDER CARRIAGE I, FIRE ❑ ® U2
F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 2
POINT OF s I I 4 COM VEH ❑ ® CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Y 6` .5 •)ryes,See Sidebar C
= HOFFMAN ESTATES IL 60192 B 1 0 BN40544 IL 2025 I 0 Si)
IL D 0 1FM5K8D84DGC49893 Owner's Insurance Company ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Jedrejak. Daniel 54-579-391-00 SAC E
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)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
W 04 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 City of Elgin traffic sign 01 ,14 /2025 03 52 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
;, 2 0 21 1 644 S LIBERTY ST ELGIN IL 60120 2 28 , , AM
0 - ❑Construction %
ry 3 ❑ 20 3 'xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
U2
—a, ARREST NAME Amin.Amar. M. 11-901-A 488000225 / ! ❑❑PM ❑Maintenance SLMT® 11 4UtilitySIMT
o NSECTION CITATION NO. ROAD CLEARANCE TIME 0
0CITATIONS ISSUED PENDING
t 2 El ARREST NAME 01 r 14 ,2025 04 25 ®PM El Unknown work zone type U1 0 AM
3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
488-Ramos.Arely 401 334-Fries 02 , 11 ,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 -<
`----'-----; m phi ICI m - INDICATE
ARROW NORTH
combination):or p3
BY 2 Is used or designed to transport more than 15 passengers including the driver C
} l �I ♦_ - (example:shuttle or charter bus):or 0
L A m 3. Is designed to carry 15fewer passengers andoperated r a or ng by a contract carve O
} } } transporting employees In the course of their employment(example:employee X
wimr+st. transporter-usually a van type vehicle or passenger car):or w
L L.___a._. - - — — - •} } 1 4. Is used or designated to transport between 9 and 1passengers,includingthedriver,
C
for direct compensation(example:large van used fors specific purose):or
— r - t l. I I 0
._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
_• I placarding(example:placards will be displayed on the vehicle). m
Not To Scale I I CARRIER NAME z
6)
N ADDRESS
Ea t
o
CITY/STATE/ZIP g
- i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- —: - USDOT NO. ILCC NO. rn
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black White
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE