HomeMy WebLinkAbout2025-00036863 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I0110110000110100
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X463848759
u, 1 U21 3 4 1 U1 3 U2 1 U1 1 U2 1 U1 1 U2 1 5 10 U, 1 U2 -3-1 .P0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00036863 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 06 10 2025 ®AM ❑YES ®NO U1 -<
N RANDALL RD Elgin 03:16
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITT
FT!MI N E S W 190 EB EXPY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ 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
Qg3 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 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Merabet. Larbi m0 D 3 / /1 9 8 1 Toyota Corolla 201 6 00-NONE it_ O I_1 DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 i , 2 FIRE ❑ ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 !T1
M 2 SY15-OTHER
5 ❑Y ONM CrUNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 16•TOP 3 *Detraction Value 7 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a 4 COM VEH ❑ El 1 00
~ ELGIN N I L 60120 B 1 0 FIRST CONTACT 12 7 ; __5 *II Yes.See Sidebar U1
Z CK29544 IL 2025 E
TELEPHONE
IL D 0 2T1 BU RH E7GC542813 State Farm ❑Y IglN U2 93 . m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 3478733-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
m �{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEOAL 0 EWES 0 m v 0 NCv 0 Dv
/1 9 y yf 3 Honda CRV 2017 00-NONE 11_"1 Qr O DUE TO CRASH rg D 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0
POINT OF s i1 �i 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •Iryes,See Sidebar
PINGREE GROVE IL 60140-9158 B 1 0 AE32061 IL 2025 I 0 Si)
IL D 0 5J6RW2H90HL049031 Pekin ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 005243427 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
)UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
W
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 06,10 /2025 03 16 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 25 28 / / ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 1 1 4 ARREST NAME Merabet. Larbi 11-306 S151000692 / / ❑PM SLMT
o N
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
El r 2 0 ARREST NAME AM
7 / / PM 0 Unknown work zone type 45
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1510-Cortes. Reyna 502 331-Ziegler 07 , 15/2025 09 00 ❑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 -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
.,� 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- I- -A- --'
} } } transporting employee in the course of their employment(example:employee
TO et,.,�j transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including w} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
0
D I I '" •
< <____a..... �� - 1/4 L } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
'1 '_�
el S. placarding(example:placards will be displayed on the vehicle). ;p
•ti.) r' -1
r CARRIER NAME
- i. i. •i... ADDRESS D
I
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
• Source of above z
MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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
White Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
Arties . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGEEXTENT: Y/T6
DUE TO ® DISABLING DAMAGE NOT DAMAGE Arties 3 TOWED B VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE