HomeMy WebLinkAbout2025-00011450 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 lfl
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037.344 6
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00011450 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 02 21 2025 ®AM ❑YES ®NO U1 -<
ALFT LN Elgin 10:39
_ g PRIVATE mo !day!yr ❑PM FLOW CONDITION ITl
FT!MI N E S W CAPITAL ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
r4T TOWED U1 Q
NAME(LAST,FIRST,M) mo
/1 9 6 5 Mercedes-Ber>100 Series 2023 00-NONE ,, 12 0DUE TOCRASH ❑ EN E
13-UNDER CARRIAGE 101 ! 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 0 171
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL S ii,4 COM VEH ❑ j$J 1 0
F.
Lombard IL 60148 0 1 0 FIRST CONTACT 1 7. •, *IIYes.SeeSidebar U1
ZEL27916 IL 2025 REAR
TELEPHONE
IL D W1 N9MOKB5PN049520 Allstate ❑Y J N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 975302060 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 Ncv 0 Dv
!1 9$7 Ford Transit Connect 2018 00-NONE 11'f 12 c,�2 FIRE DUE O CRASH 0 ® U2 98 C o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •t •0istraction Value 0
POINT OF 8 � ll—4 COM VEH D ® Ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR &
FIRST CONTACT 7 Q _,�_5 •ItYes,See Sidebar
Z Crystal Lake IL 60014 0 1 0 460006D IL 2025 RE 0 N
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IL D 1 FTBW2CG9J KB36533 Ace American ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Crown Associates ISA H10836554 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE! (EMS) (HOSPITAL)
1 3 06 / F 2 4 0 1
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S/ / #OCC D
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 02,21 l2025 10 40 ®❑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 5 C)
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o� 2 0 2 14 I ! 0 PM ❑Construction
Z3 0 xi CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
oEl 11 1 ARREST NAME Khan. Muhammad.J. 11-901-A 327003091W / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
30
t 2 0 ARREST NAME AM
T 1 1 ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 30
327 Hromadka.Scott 901 275-Engelke / / ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
co
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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. 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?
❑ Yes II No ElUnknown A
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
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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
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE