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HomeMy WebLinkAbout2025-00042210 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003874205 u, 1 U21 2 1 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ElS501-S1,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-0004221 O VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n N LIBERTY ST Elgin 05:04 ® ❑ RELATED ®Y 0 N 07 01 2025 DAM YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill FT l MI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0 FOR DAMAGED AREA(S) FRObit TOWED U1 O Khosty. Noor Wali 1 1 / yr 13-UNDER CARRIAGE ©,I �:. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTHER OTAL(ALL) DISTRACTED 0 0U2 1 M922 M 2 4 ❑Y SYSTEM❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 76.70P 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4 COM VEH 0 0 1 n F. FIRST CONTACT 12 7__,_—6_,__5 *uves.See Sidebar U1 0 Z Sleepy Hollow I L 60118 0 1 0 EZ14799 I L 2025 REAR TELEPHONE IL D 0 5N PD84LF6H H 186403 FIRST CHICAGO INSURANCE C ❑Y ®N U2 I' IL'in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 KHOSTY. NOOR WALI ILS 1071061-01 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 Ncv 0 Dv Yr /2 0 0 1 Acura TSX 2009 00-NONE „ " Oj-_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 1; FIRE 0 ® U2 C M 2 5 SYSTEM IN 0 ENGAGED 0 ®-OTHER O9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i ,-4 COM VEH 0 ® U1 CO F,,, FIRST CONTACT 10 Y��_,-r=5 C.If Yes,See Sidebar C ELGIN IL 60120 0 1 0 EG56490 IL 2025 ISi)0 M IL D 0 JH4CU26699C033680 BRISTOL WEST INSURANCE CO ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 GODINEZ. ELSA GO1 3057839 04 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS))(TELEPHONE) (EMS) (HOSPITAL) 1 5 10 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y Z N 1 ® 11 4 07,01 /2025 05 04 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 ❑ 23 28 1 / ❑PM ❑Construction Z 3 ❑ El CITATIONS ISSUED El PENDING SECTION CITATION NO. WSARRIVED TIME 1 ❑AM 0 Maintenance U2 o 1 ❑ 11 4 ARREST NAME Khosty. Noor Wali 11-1204-B 1564000013 / / El PM SLMT • 1$!CITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility L- t 2 ® 1 1 4 ARREST NAME Khosty. Noor Wali 11-601-Ax 1564000014 071 01 /2025 06 20 0 PM 0 Unknown work zone type U1 25 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1564-Rea. Desiree 201 08 / 19,2025 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- }-- --I-- --' } INDICATE NORTH combination):or -I �N� Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or C) r r • L L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or lP 4. Is used or designated to transport between 9 and 15 passengers,including (I) i_ .:. .J.... ...I. 4Ipj --- } } } C g po passen m,includi the driver, '� _ for direct compensation(example:large van used for specific purpose):or O t'+rnt ,� L L____a____. �» �__ _ i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m (���DQt -wea 0 i I placarding(example:placards will be displayed on the vehicle). :0 D' '^.v.'--� CARRIER NAME Z t r. ADDRESS 1 r CITY/STATE/ZIP gC) MOTOR CARR.ID 0 Interstate 0 Intrastate 5 1 I r 1 ❑ Not in Comm./Gout. 0 Not in Comm./Other ----------1 USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m v 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 Gold 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE