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HomeMy WebLinkAbout2025-00003668 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 I I IIII IIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003699355 u, 1 U21 1 1 1 U1 5 U2 1 U, 1 u2 1 U, 1 U2 1 1 10 u1 6 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 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 0 AMENDED YR 2025I 2025-00003668 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 ® ❑ RELATED ❑Y ®N 01 17 2025 ❑AM ❑YES ®NO U1 -< SHALES PKWY Elgin mo /day/yr 01.19 ®PM FLOW CONDITION m _ PRIVATE �O�(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 cn F !MI N E O W Route 20 WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 gi 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 4 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Shakil.Waqas 0 5 yr 13-UNDER CARRIAGE © NI ,I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 4 rn M 2 5 ❑Y ®SNEM❑ n is-OTHER UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a �i COM VEH 0 Ea 1 0 H 1- BARTLETT I L 60103 0 1 0 FIRST CONTACT 11 7_;1 __s *lIYes.See Sidebar U1 ZEQ47561 IL 2025 REAR TELEPHONE IL D 0 5J8TB4H39HL019879 ERIE NSURANCE ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Q061715306 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER yr 12 o 13-UNDER CARRIAGE 10, 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distracion Value 9 U1 0 POINT OF s i 4 C.OM VEH 0 ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 �S:_ C FIRST CONTACT 1 7 -5 •If Yes.See Sidebar Hoffman Estates IL 60192 0 1 0 BX98695 IL 2025 I0 Si) IL D 0 JTEEP21A840020857 Travelers Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 6109904502031 BAc 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) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 01 ,17 /2025 02 03 ®AM in a Work Zone? ®N DIRP co 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 C) ai 2 0 06 99 01,17 ,2025 02 03 ®PM ❑Construction * R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 z J ❑AM ❑Maintenance U2 - ®a, ARREST NAME Shakil,Waqas 11-802-B S1544-000067 01/17/2025 02 09 Igi PM oSLMT U 11 1 CITATIONS ISSUED 0 PENDING o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility r 2 ElARREST NAME Shakil,Waqas 11-601 S1544-000066 01/17 /2025 01 19 ®PM 0 Unknown work zone type U1 35 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1544-Solis,Yulissa 301 237-Copland 02 ,25/2025 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 -1-- , A CMV is defined as any motor vehicle used to transport passengers or property and: Z 01. Has a weight rating more than 10,000 pounds{example:truck or truckrtrarler -< ` ` ' ' /"\ • INDICATE NORTH comWrtation)or p3�" 11141 ,, N i BY ARROW 2 Is used or designed to transport more than 15 C ` - (example:shuttle or charter bus):n or passengers including the driver r: % Li/or 10 str�vr r r r0 / 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O _=`_ / t t t t transport) employees in the course of their employment transportingpbymar):or(example:employee co z transporter-usually a van type vehicle or passenger car):or co •4. Is used or designated to transport between 9 and 15 passengers,including N ` �.---"�---- o >-r, - t 9 t� passen rs,incI di the driver.for direct compensation(example:large van used for specific purpose):or L L____a.....I - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p � I,/ ` CARRIER NAME Z ,�' �� / ADDRESS 0 ,., to �.:r // CITY/STATE/ZIP g / i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate / ❑ Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. m 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 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 M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Gold 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