HomeMy WebLinkAbout2025-00034507 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003S38282
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00034507 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
S STATE ST Elgin 01:43
® ❑ RELATED ®Y 0 N 05 30 2025 ❑AM ❑YES El NO U1 —<
_ _ PRIVATE mo !day!yr ®PM FLOW CONDITION III
FT!MI N E S W MORGAN ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 Icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
00-NONE
FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Guendouzi.Oussama mo yr Toyota Prius 2008 13-UNDER CARRIAGE 11,) 12! O DUE TO CRASH El EN
FIRE 0 ® E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U 2 DISTRACTED ® 0 U2 2 I'Tl
M 2 SY4 ❑Y ❑STM NE®UNK VEH. 9 ATCRASHD 9 99-U 15-UNKNOWN THER916•TOP3 `Distraction Value 6 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI 6 �i 4 COM VEH 0 j$J 1 0
F.
Des Plaines I L 60016 0 1 0 FIRST CONTACT 1 7_; -_5 *If Yes.See Sidebar U1
Z ET68625 IL 2025 REAR
TELEPHONE
OTH D JTDKB20U983299600 United Security Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Fouad. Bouras ULS115931100 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NUV 0 NCV 0 DV
!1 9 6 8 Hyundai Elantra 2008 00-NONE 11 12..-_, DUE TO CRASH rg ❑ 2
o 13-UNDER CARRIAGE I c. 2 FIRE 0 ® U2 C
Ti
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 016•TOP 3 X
❑Y ❑N El UNK VEH. AT CRASH 99-UNKNOWN II *Oistracton Value 9 0
( CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 NT OF O Q.'{� 5 CIOMs geeSidebarH ❑ ® U1 CO
ELGINZ IL 60120 0 1 0 X788276 IL 2025 0 N
D
IL D KMHDU46D28U298459 Magnum Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 10 =
Same I LP2571196 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 07 / M 2 4 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 4 05,30 l2025 01 43 ®pm in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 0 06 14 , , 0 PM ®Construction *
1
Z 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Guendouzi.Oussama 11-804-A 410000731 , / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
❑ 30
t 2 El ARREST NAME AM
7 1 r ❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? D Y 30
410-DeLeon.Jessica 701 275-Engelke 06 , 17,2025 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
I 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 -
` ` -'- ' • INDICATE NORTH combination):or .Z-1
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or
Not 7b Sate ) , 3. Is designed to carry15 or fewer
L A. passengers and operated a contract carrier 0
JI } transportng employee In the course�of their empbyment(example:employee
L L.___ ____� transporter sed or d usually designated to transehicle or rt between9andr 15 passengers,ssen rs,including the driver. C
1 i Morgan?St t } } for direct compensation(example:large van used for specific purpose):or
' L.._-a____. ♦ - L i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
II i : placarding(example:placards will be displayed on the vehicle). X/
;; CARRIER NAME Z
1
ADDRESS
T.
CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 I ❑ Not in Comm./Govt. Not in Comm./Other
1 1 '
sisest.�at 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.
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 M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Blue
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE