Loading...
HomeMy WebLinkAbout2025-00033854 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 hlfl lI II101111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003833..24 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 u2 1 U, 1 U2 1 1 15 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 7 VEHICLE/PROPERTY ®OVER 51,500 ®NOT ON SCENE(DESK REPORT) ❑AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00033854 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m1255 FLEETWOOD DR Elgin06:55 ® ❑ RELATED ❑Y ®N 05 27 2025 ❑AM ❑YES IX]NO U1 _ _ g PRIVATE mo /day!yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 15 Co ❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 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 2 0 FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Chaudhry.Aishah.G. 0 6 / yr 13-UNDER CARRIAGE ©,I O i.-2 FIRE 0 10STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S �i 4 COM VEH 0 Ea 1 0 I . Hoffman Estates IL 60169 0 1 FIRST CONTACT 11 7_; __5 *lIVes.See&debar U1 Z BV92565 IL 2025 REAR TELEPHONE IL D 0 4JGFD6BB0SB362624 State Farm ❑v IlN U2 m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Chaudhri.Amjad. M. 33918075FP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 NCv 0 Dv !1 9 6 8 Kia Motors Colporento 2018 00-NONE 11-.. t2..0 DUE TO CRASH ❑ 2 x yr o 13-UNDERCARRIAGE 10,1 }. 2 FIRE ❑ ® U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6-TOP 3 X ❑Y NiN ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 0 POINT OF 8 i1�I 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 1 Y _,__5 •• •If Yes,See Sidebar Z Chicago IL 60617 0 1 EJ20564 IL 2025 I:EaR 0 C Z IL D 0 SXYPG4A51JG351846 Kemper ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Chaudhri.Amjad. M. 12RA000062241 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y / U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 CD 11 1 05,27 l2025 07 42 ®pm in a Work Zone? NJ DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) v 1 T 2 0 2 28 1 / 0 PM 0 Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a, ARREST NAME / / El PM o N ® 11 5 0 • CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT ARREST NAME AM TI 2 ❑ ❑❑PM 0 Unknown work zone type U1 / / n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 554-Stebbins. Blake 701 391-Jacobucci / / ❑❑AM Workers present? ®N U2 10 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 } 1255?F�eetwfood?Dr. ® combination):or p3 }----r----, r INDICATE NORTH —1 Not To Scale I _ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } (example:shuttle or charter bus):or 0 L A 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- I I H W I H transporter-usually a van type vehicle or passenger car):or w 4. Is used or designated to transport between 9 and 15 passengers,including w } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L____a____. ` _ t i. i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires -u placarding(example:placards will be displayed on the vehicle). XI . 1 111•••••••• . 1. L. 1.._ CARRIER NAME ADDRESS Z 'Z CITY/STATE/ZIP 0 g I - i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5 UOIt2 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 ; _Y_ __1 r - ' ' USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 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 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 Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 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 Black Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO: SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE