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HomeMy WebLinkAbout2025-00036534 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110000100 fll II 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0038:4502 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00036534 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n JEFFERSON AVE El In 10:41 ® ❑ RELATED ®Y 0 N 06 08 2025 ®AM YES ®NO U1 -< _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MFTlMI N E S W WAVERLY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NIA/ 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 T TOWED U1 Haji. 0Saeedurrehman. H. Toyota Corolla 2025 00-NONE Oj 0 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE ©I 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) (D).:`':'.. 2 DISTRACTED 0 0U2 0 171 M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER O9 t6-TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,II a I,.4 COM VEH 0 Igl 1 C) ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 t _; __5 *Ir Yes.See Sidebar U1 0 Z FH68403 IL 2026 E TELEPHONE IL D 5YFS4MCE4SP241242 Geico ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Haji. Mariyam. H. 6210968977 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NAV 0 NKV 0 DV /1 9 9 3 Chevrolet Trax 2020' 00-NONE 1,1 ' 12..0 DUE TO CRASH 0 ❑ 2 73 o 13-UNDER CARRIAGE I FIRE ❑ ® U2 c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 10-TOPO3 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-il�.- 4 COM VEH ❑ ® U1 CO FIRST CONTACT 2 Y -`-�•byes,See Sidebar ELGIN IL 60120 0 1 0 CF49777 IL 2025 I 0 N M IL D KL7CJPSB3LB066873 Progressive ❑y ®N RDEF .73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I = Same 940818559 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 11 / F 2 4 0 1 0 m / / #OCCS D / / UI 2 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u AMN 1 El 11 4 61 //2 /25 10 41 ®❑PM in a Work Zone? NJ DIRP > co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM o If YES check one below: U1 7 C) ", T 2 ❑ 2 99 / / ❑PM- ❑Construction R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -, 1 ® 11 4 ARREST NAME Haji.Saeedurrehman. H. 11-1204-B 1545-321 / / ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility t 2 ❑ ARREST NAME AM T / / pM El Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 30 1545-VanEycke. Brier 201 / / ❑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 truckrtrailer -< ----; combination):or —IINDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' (example:shuttle or charter bus):or C) Not To Scale ° 3. Is desgned to carry 15 or fewer passengers and operated by a contract career O . - . transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N } } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L ; w,, ?11- i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m =r I UM placarding(example:placards will be displayed on the vehicle). X/ v - —I CARRIER NAME Z ADDRESS 0 CITY/STATE/ZIP 00 " " —TIMI - MOTOR CARR.ID 0 Interstate 0 Intrastate l I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE