HomeMy WebLinkAbout2025-00016383 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00016383 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 FI
STANDISH ST El08:02
® ❑ RELATED ®Y ❑N 03 13 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W ELY ST COUNTY PROPERTY El ® N DOORING ICIy #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
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
NAME(LAST,FIRST,M) Sakhizada. Habibullah mu /
13-UNDER CARRIAGE 101 12 12 FIRE 0 ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 m
M 9 M IN ENGAGED
9 ❑Y ❑N SYSE❑UNK VEH. 9 AT CRASH 9 ®-OTHER UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 il_6 I,.4 COM VEH ® 0 1 0
Fort Worth TX 76115 0 9 0 FIRST CONTACT 99 7_; __5 *!ryes.See Sidebar U1
ZP1082024 IL 2025 REAR
TELEPHONE
TX A 7 3AKJHHDR2MSMS4303 Colonial insurance ❑Y ®N U2 1—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Penmark GL0147-23B 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 (,Xj
m p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NOV 0 DV
yr g ) 10;j 12 c, 2 FIRE ❑ ® U2 2 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9:1,6•TtOP 3 0 ® SPDR 0
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 11 6 j�',_ COM VEH ❑ ® C
F,,, FIRST CONTACT 7 Q11 -5 •IfYes.See Sidebar
ER22086 IL 2026 I 9 fp
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2C4RDGCG9ER234910 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Brown. Herbert. L. 988416692 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
u 1 El 18 1 03,13 /2025 08 02 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0
2 0 18 1 18 28
! r 0 PM• ❑Construction *
1
N 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o D 1 El 11 1 ARREST NAME Sakhizada. Habibullah 11-601-Ax 1518000407 r ! ElPM SLMT
I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
8 N ❑AM30
T 2 ❑ ARREST NAME Sakhizada. Habibullah 11-402-A 1518000407 , r ❑PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1518-Versetto. Elisa 701 04 , 15,2025 09 00 ❑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 -<
` ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} 0 - i.i. e. r r (example:shuttle or charter bus):or
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I
® i. . - . transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.__-a-_- — — — - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
C
...'' I -_�;;. } } } •
for direct compensation(example:large van used for speific purose):or 0
L L--_-a-___- t i I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
'D
F • placarding(example:placards will be displayed on the vehicle). m
'I - -1
I I 7 I -I
i
i __NaTos _J ADDRESS 1250 MARK ST T.
NAME Penmark
CITY/STATE/ZIP Bensenville I IL 160106 n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other
%------ --1 - % % % usDOT No. 3818154 ILCC NO. rn
XI
Source of above Z
. -I
Were HAZMAT placards on vehicle? 0 Yes ® 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 ® 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'7 ❑Yes ®No 2
TRAILER VIN 1 1 G R1 P0629RK523338 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE