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HomeMy WebLinkAbout2025-00038213 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111 011011000 01110110 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003862103 U111 U21 3 4 1 U1 4 U2 2 U1 1 U299 1.11 1 U2 1 4 10 U1 1 U2 3 *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 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash ®AMENDED YR 202512025-00038213 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n N MCLEAN BLVD Elgin09:27 ® ❑ RELATED ®Y 0 N 06 15 2025 12,— ❑YES El NO U1 _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIA/ 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FROM© T TOWED U1 I� Mayen Es 0 2 / yr 13-UNDER CARRIAGE I O; FIRE ❑ NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 0 m M 9 SY15-OTHER 8 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�6 �i COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_: __5 *II Yes.See Sidebar Ut Z FC23991 IL 2026 REAR TELEPHONE IL D 0 WAUFFAFLOFN019401 Kemper ❑Y ®N U2 I- 11 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m 99 9 Palacios [spin.Gabriel.A. 12RA000063369 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑N4v 0 NCv ❑DV !1 9$6 Honda Accord 2021 00-NONE 1("j 12 NT..-_1 DUETO CRASH rg ❑ 2 x o - 13-UNDER CARRIAGE 10 1 2 FIRE ID El U2 C il M 9 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII 6 , 4 COM VEH 0 ® U1 CO FIRST CONTACT 4 Y .j= 05 C.(ryes,See Sidebar C ELGIN IL 60123 0 1 0 FA22672 IL FIRST 0 Si) Z IL D 0 1 HGCV2F36MA016569 Geico ❑Y ®N RDEF Xl EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 6184746946 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 06,15 l2025 09 27 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 0 50 18 N 1 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction >F SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME / / _ ❑PM ' 1 ® 11 1 0 CITATIONS ISSUED PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ t 2 El ARREST NAME 06/15 l2025 10 25 ®PM 0 Unknown work zone type El AM U1 30 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? Y 30 1540-Allah. Muhammad 607 - , ❑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 unitshave been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A N?Mdean?Blvd ADDITIONAL UNITS FORMS. -- •- + Inpi I - 0A CMV is defined as any Bator vehicle used to transport passengers or property and: z I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ' }--_-r--' j I I } combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C II (example:shuttle or charter bus):or 3. Is designed to carry15 or fewer passengers and operated a contract carrier O }_---------i _ ` } } 1- transporting employee �...j In the course of their employment(example:employee .i I ` transporter-usually a van type vehicle or passenger car):or co_ _ } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y Until — Larkin?Ave for direct compensation(example:large van used for specific purpose):or O __ __ � r i. < 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p I 1 N 1CARRIER NAME Z I t Not To Scale I ADDRESS D 0 CITY/STATE/ZIPI` ¢?Mires ?Blvd _ i. 4. MOTOR CARR.ID 0 Interstate El Intrastate . . r I 0 Not in Comm./Govt. Not in Comm./Other ; _ I I USDOT NO. ILCC NO. C x Source of above 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? ❑ Yes II No ElUnknown A 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' M TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE