HomeMy WebLinkAbout2025-00040738 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0036 7366
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00040738 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
WEST BARTLETT RD Elgin09:32
® ❑ RELATED ❑Y ®N 06 25 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W RUZICH DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ Cook HIT ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
0 9 /
yr 13-UNDER CARRIAGE VI
IE
10.I !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 SY5 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i COM VEH 0 j$J 1 0
H 1- BARTLETT IL 60103 0 1 0 FIRST CONTACT 11 T_; __5 *II Yes.See Sidebar U1
Z EP64004 IL 2025 REAR
TELEPHONE
IL D JTMABACA2RA055842 Progressive ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 969894513 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ElY ❑ N 2 2 0
p; D%VER ❑ PARKED 0 DRIVERLESS 0 KO 0 PEDAL 0 EWES 0 row 0 Ncv 0 Dv CIRCLE NUMBER(S) U1
1 9 6 2 Toyota Camry 2007 00-NONE 0.,. QL-_, DUE TO CRASH rg ❑ 2 x
...
y yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
i1i
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 4 COM VEH 0 ®
FIRST CONTACT 11 8 7 L_5 •If Yes.See Sidebar U1 CO
•
= BARTLETT IL 60103 0 1 0 DD43977 IL 2025 REARO C
Z
IL D 4T1 BE46K07U635602 All State ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 811 730 255 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 COMED Electrical pole 358105 06,25 ,2025 09 32 ®AM in a work zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
Eri 2 ❑ 31W710 SPAULDING RD Elgin IL 60120 2 28 06,25 ,2025 09 32 ®PM
• ❑Construction >F
R ❑ Ei CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Yassob.Zain 11-902 W1534000273 06,25,2025 09 40 ®pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
r 2 ElARREST NAME 06/25 ,2025 11 47 ®PM ElUnknown work zone type U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
1534-Santiago.Jorge 401 - , , ❑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 I ADDITIONAL UNITS FORMS.
r -- r••--, , II A CMV is defined as any motor vehicle used to transport passengers or property and: z
4 N v VlBardernsd 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }---_-I-----; II ".. } combination):or -I
INDICATE NORTH
L' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale a I I i (example:shuttle or charter bus):or 0
i ,
r I �► I • 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
- .----------i
} } } transporting employees In the course of their employment(example:employee
y a van type
L L.___a__ 4alsuosedorrter- lltoehbetweeicle or n9andr15r) ssen rs,induding[hedriver,
�,. } } } designatedtransportpassengers, rC/1
for direct compensation(example:large van used for specific purpose):or O
I I �
< .I. ,�� 5 _ t } } } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
ICI placarding(example:placards will be displayed on the vehicle). ;p
- Rruldr7Dr - D
CARRIER NAME Z
- -- ADDRESS 0
w
CCITY/STATE/ZIPOg
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0I I T I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
;....Y. ._.; - USDOT NO. ILCC NO. m
1 XI
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? A
❑ Yes II El 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
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
Silver Black
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 DAMAGE EXTENT: 3 TOWED BY/T6
DUE TO ® DISABLING DAMAGE Redmons VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE