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HomeMy WebLinkAbout2025-00017272 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 I01101100 Hill I 11 11111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003762224 u, 1 U21 1 1 1 U1 8 U2 1 U1 1 U2 1 U, 1 U2 1 1 12 U, 13 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00017272 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl ® ❑ RELATED PRIVATE ❑Y ®N 03 18 2025 ®AM ❑YES ®NO U1 -< RT20 EB Elgin mo /day/yr 08:47 ❑PM FLOW CONDITION m �O 1C.'J!MI N E S © South State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 8 Cl) Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 -I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O (8: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 0 7 / Toyota Corolla 2010 00-NONE 0 O _1 DUE TOCRASH ® ❑ 13-UNDER CARRIAGE I FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 4 in F 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, �--it 6 �i_;_ COM VEH 0 Ea 1 0 f. FIRST CONTACT 11 7_; _5 *II Yes.See Sidebar U1 Z Algonquin IL 60102 0 1 0 CD15752 IL 2025 REAR TELEPHONE IL D 0 1 NXBU4EE5AZ327511 State Farm ❑v ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Khan. Muhammad.A. 0373737-SFP-13 1 1— '6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 eu p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 KDV 0 DV CIRCLE NUMBER(S) U1 $ 1 9 8 7 Freightliner Cddplk 2023 00-NONE ,t"i 12-- DUE DUE TO CRASH 0 2 x 0 13-UNDER CARRIAGE 10 1 2 FIRE ®❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOPO3 * X a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O 0istracllon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si�, 4 COM VEH ® ❑ U1 CO FIRST CONTACT 3 7 , _5 •• •It Yes,See Sidebar C Z Wolcott I N 47995 0 1 0 3283892 I N 2024 REAR 0 Si) M IN A 7 1 FUJ HTDV6PLU L4624 Great West Casualty Co. ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same MCP64871E BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 ❑Y U2 Z u 1 ® 11 1 03,18 ,2025 08 47 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) o" 2 ❑ 20 28 1 / ❑PM ❑Construction * Z 3 ❑ lyg CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Khan. Kehkashan 11-709-A S348001344 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility AM U, 45 t 2 El ARREST NAME 031 18 r2025 09 30 [0 PM ❑Unknown work zone type 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45 348-Rapacz.Jordan 701 368-Davenport 04 , 15/2025 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 -< ` ` --I -' r INDICATE NORTH combination):or -I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I - } (example:shuttle or charter bus):or X I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X 'ITT' ,l l transporter-usually a van type vehicle or passenger car):or C __ rso.nsnonreeraeema - } 1- } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N ——— for direct compensation(example:large van used for specific purpose):or O L A i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires III rn placarding(example:placards will be displayed on the vehicle). XI D Rmrlo�rrea� CARRIER NAME Venture Logistics Z a ADDRESS 1101 HARDING CT O ® r,�� „> CITY/STATE/ZIP Indianapolis I IN 146217 g MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other ; _Y_ __1 - USDOT NO. 911759 ILCC NO. m 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. Xl Xl 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 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 ®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 Gray White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE