HomeMy WebLinkAbout2025-00018741 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 0 IftIl
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV
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INVESTIGATING AGENCY DAMAGE TO ANY ❑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 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00018741 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
100 NATIONAL ST Elgin08:01
® ❑ RELATED ❑Y ®N 03 25 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Kane 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FRONT�OUETOCRASH TOWED U1 0
Juarez.Adrian 1 1 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 m
M 2 4 ❑Y ® is-OTHER
SYSTEM
❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI 6 )i 4 COM VEH 0 Ea 1 C)
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 6 tz::L:Q_O6 =Ir Yes.See Sidebar U1 0
Z EJ78143 IL 2025 E
TELEPHONE
IL D 0 JF1VA2E63M9802917 State Farm ❑Y ®N U2 r
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1758046-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
m N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NOV ❑DV CIRCLE NUMBER(S) U1
!1 9$9 Mazda CX-3 2021 oo-NONE ,�_"j t2..-_, DUETOCRASH p !g 2 x
o 13-UNDERCARRIAGE 101, 2 FIRE 0 ® U2 C
c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
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NT OF
H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 6 Q_�LOI`O•CIOMesvSee SidebarEH ❑ ® Ut tC
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ELGIN IL 60123 0 1 0 L674445 IL 2025aR
M
0 3MVDM BBLXM M272257 American Alliance Insuran ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same 41005-69930-69 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER ui _
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 1 5 03,25 l2025 08 01 ®❑pM in a Work Zone? ®N DIRP co
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PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 2 C)
cv 2 ❑ / 1 0 PM• ❑Construction
Z3 ❑ xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 2
a1 ® 11 1 ARREST NAME Leon. Norberto.J. 3-414 1540-W164 / ! El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
AM u, 35
t 2 0 ARREST NAME 03!25 l2025 09 36 [M PM 0 Unknown work zone type
n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
1540-Allah. Muhammad 401 310-Zierk 05 , 13,2025 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.
0 A CMV is defined as for vehxae used to tra and:
r ----,5-••--, ; any mo nsport passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} i.-- -;-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
X1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' J. , } (example:shuttle or charter bus):or
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3. Is
L L.___A.. 1 i. <--_- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < .---_-a-___� , J. , , 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____.I L L L ...._-..i._ 1 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
i.
ADDRESS 0
th
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m
Z
GVWR/GCWR 1
El <10,000 0 10,000-26,000 0 >26,000 z
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 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
73
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
u 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE