HomeMy WebLinkAbout2025-00023990 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 IVI
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY IN OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00023990 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m
® ❑ RELATED ®Y 0 N 04 16 2025 ®AM ❑YES ®NO U1
S MCLEAN BLVD Elgin10:41
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W RT20 EB COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 4 !
yr 13-UNDER CARRIAGE fa lE
t !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 SYSTTHER
4 ❑Y ONEM❑UNK VEH. 0 AT CRASH IN ENGAGED 0 99-UNKNOWN 9 76-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, it 6 jl COM VEH El El 1 n
FIRST CONTACT 4 7__11---:;_9 .irYes.SeeSidebar U1 0
Z 60110 0 1 0 31987V IL 2025
TELEPHONE
AZ A 7 1 M 1 AA18YX5N 158034 Country Financial ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same AB9278047 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 20 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
!1 9 4 3 Ford F150 2000' 00-NONE 0,' o 0DUE TO CRASH 0 ❑ 2 x
yr13-UNDER CARRIAGE FIRE ID El U2
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracti n Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6- 6 ii, COM VEH ❑ ® ut W
I- FIRST CONTACT 1 O7 -5 •If Yes.See Sidebar
Z SOUTH ELGIN IL 60177 B 1 0 43721W-B IL 2026 REAR 0
D
IL 0 1 FTNX21 SXYEA21501 Statefarm ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
South Elgin Fire 99 9 Same 2238867SFP13 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)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2Z
N 1 ® 11 4 04,16 /2025 10 41 ®❑AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 0 25 99 / / ❑PM ❑Construction *
R 3 ❑ ❑CITATIONS ISSUED tffi PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME Ishak.Shabe.Y. 11-306 399004107 / ! ❑PM SLMT
oN 1 ® 11 4 CICITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
r 30
2 ❑ 11 4 ARREST NAME / r AM
T ❑❑PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
399-Kazy-Garey. Daniel 701 334-Fries 05 /20,2025 09 00 0 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 -<
c ` -'- r' INDICATE NORTH combination):or -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 0
I
_._._, I L~__ -~' 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I _ } } } transporting employees in the course of their employment(example:employee X
I �. transporter-usuallya van vehicle or
Po type passenger car):or C
-- `� I 17.-
} } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, fn
L <. _a_ _�
2.
, !• -r� for direct compensation(example:large van used for specific purpose):or O
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L L_ ---------- t. L L L 1 L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
V� placarding(example:placards will be displayed on the vehicle). :0
.��" `� D
'i" t/ 1 I I \� CARRIER NAME S.I.Trucking Z
� 'i „ r ADDRESS 3522 BLUE RIDGE CT
I
CITY/STATE/ZIP I I 60110 n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
- USDOT NO. ILCC NO. 140954
x
Source of above z
. 0 Yes No ❑ Unknown 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 ❑Unknown Out of Service ❑Yes ®No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAEP 0 Yes ®No 2
TRAILER VIM 1 1T9FC24BXT1066881 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
White Maroon
u 1 TOWED •
TOTAL VEHICLE LENGTH 38 ft. NO.OF AXLES 5
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Allen's I Allen's Towing . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE 5 LOAD TYPE 5
Redmons/Owners Residence -