HomeMy WebLinkAbout2025-00032830 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 0 ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
[E]AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00032830 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 05 23 2025 ❑AM ❑YES ®NO U1 -<
N STATE ST Elgin12:57
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
0 8 ! yr
Murillo. Montagut.G. Ford Edge 2015 00-NONE ,, • 12 , DUE TOCRASH ❑ EN
13-UNDERCARRIAGE fal 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 3 <<T1
F 9 4 ❑Y ®SYSNEM IN DUNK VEH. 0 AT CRASH 0 99-UNTHER
KNOWN 9 76-TOP�3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 :il 6 �i, COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 2 7_; __5 *Ilves.See Sidebar U1
ZEV28956 IL 2025 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
( 2FMTK4G92FBC10847 Kemper ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 12RA000028698 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Refused ❑Y 23N 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑Nuv 0 NOV ❑DV
!2 0 0 2 OM Mitsubishi Outlander 2017 Do-NONE ,�_' 12 "_, DUE TO CRASH ❑ C 2
0 ® C)
Yr 13-UNDER CARRIAGE ( 2 FIRE ❑ El U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y 10 N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9 0
i1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 1 O 8 7- i 4 COM VEH D ® U1 coB t.. If Yes.See Sidebar 5 •
H Woodstock IL 60098 0 1 0 AL37962 IL 2025 REAR0 N
IL D 0 JA4AD2A31 HZ020031 State Farm ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2779339-SFP-13 BAC
$
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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
co
u 1 CD 11 1 51 )51 ,025 06 00 ®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 5 C)
F.; T 2 ❑ 04 2 I / ❑PM D Construction *
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME / / ❑PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2ARRESTNAMEAM
TEl
❑PM ❑Unknown work zone type U1
El / / ❑
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1540-Allahi. Muhammad 501 275-Engelke 61 , 01 /025 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.
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 ` --I -' I. INDICATE NORTH combination):or —I
I I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} i I I I - } (example:shuttle or charter bus):or 0
x
I I I 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
} I.- } transporting employees In the course of their employment(example:employee X
16 I transporter-usually a van type vehicle or passenger car):or w
I- L.__-a-_ 12I -- I. } 1.} 4. Is used or designated to transport between 9 and 15 passengers,including the driver, y
for direct compensation(example:large van used for specific purpose):or O
< .I. wM4..,,orot IOatkacperat - l. i . i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
N / placarding(example:placards ),
Wcartli exam le: will be displayed on the vehicle XI
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S`I A.
CARRIER NAME Z
�£nt N ADDRESS 'O
nror m sows I D
I I�
I I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --4. - USDOT NO. ILCC NO. m
Source of above z
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. M
M
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 I ❑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 VIM 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
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE