HomeMy WebLinkAbout2025-00032840 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036318.86
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00032840 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
1290 BLUFF CITY BLVD Elgin 01:56
® ❑ RELATED ❑Y ®N 05 23 2025 ❑AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ FT/MI N E S W Cook 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
Qg3 DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0 Icy CI Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n
FOR DAMAGEDAREA(S) FRO t TOWED U1 Q
NAME(LAST,FIRST,M) I mo
/1 9 4 6 Toyota Avalon 2004 00-NONE „. (2) , OUETOCRASH ® ❑
13-UNDER CARRIAGE FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED ❑ 0 U2 2 rn
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_i� 6 �i 4 COM VEH 0 j$J 1 0
H 1- BARTLETT I L 60103 0 1 0 FIRST CONTACT 1 7 . __5 *IrYes.See Sidebar U1
Z SHINI23 IL 2025 Ismi
TELEPHONE
IL D 0 4T1 BF28B54U348413 State Farm ❑Y Il N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 2612293-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 23N 2 ou
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❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 DV
yr Volkswagen Atlas 2024 00-NONE 1i_` t2�"_, DUE TO CRASH ❑ C 2
o 13-UNDER CARRIAGE o I 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16•TOP 3 0 ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracllon Value 9 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I ; 4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 8 v. i i:s •It Yes,See Sidebar C
CM65878 IL 2025 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 1V2AE2CA9RC221399 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Chaudry.Amir 981663148 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 1 01 / F 9 4 0 1 0
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/ / #OCCS D
/ / UI 2 D
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 18 3 05/23 /2025 01 56 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 0 06 18 / / ❑PM ❑Construction
Z3 0 I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
o1 ® 1 1 3 ARREST NAME Hussain. Raja. M. 11-801-A 1540-227 / / ID PM SLMT
o N -
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 El ARREST NAME 05/23 /2025 02 56 ®PM 0 Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1540-Allah. Muhammad 401 275-Engelke 06 / 10/2025 01 30 El NI ®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 truckrtrailer -<
i- '---.r----1 ' °�'"°�`r°r"tl_ _ INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
- ------I----; transporting employeened to slin the course 5 or fewer passengers
rhea emaployment nd operated
xample:employee
transporter 1 � }
03
L L.___a____. 4alsuosedordestlnatedto trany a van type sport between9 and r15r) ssen rs,indudingthedriver,
.._.,-----�'--— } } } for direct compensation(example large van used for specific purpose):or
L L..._a____. 'i, ( t Is any vehicle used to transport anyhazardous material(HAZMAT)that requires� 5m
r .,. '--� placarding(example:placards will be displayed on the vehicle). ;p
eWmaq?errd D
CARRIER NAME Z
Z
ADDRESS 0
D
rn
NCITY/STATE/ZIP 0
Not 7b Scale MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
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
White Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE