HomeMy WebLinkAbout2025-00047118 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 HI 00 IOU IOU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0038D7125
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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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00047118 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED PRIVATE ❑Y ®N 07 21 2025 ❑AM ❑YES N NO U1 -<
ST CHARLES ST Elgin mo /day/yr 01.32 NPM FLOW CONDITION M_
01 DO/MI O E S W Hammond Ave COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 2 Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROM TOWED U1 O
NAME(LAST,FIRST,M) g mo
/1 9 8 6 General Motof2500 2020 00-NONE „. Q 0 OUETOCRASH ® ❑
13-UNDER CARRIAGE FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 0 DISTRACTED 0 0 U2 2 IY1
M 2 4 SYTM❑Y ®S NE DUNK VEH. 0 AT CRASH 99-UNKNOWN THER9 t6•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8,_1COM VEH 0 0 1 8 �i 4 0
F. FIRST CONTACT 1 7 . -;__5 *Ir Yes.See Sidebar Ut
Z Genoa IL 60135 0 1 0 134427C IL 2026 Is
TELEPHONE
IL D 0 3C6UR5CJ8LG282307 State Farm ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 984391194 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑lily 0 N CIRCLE NUMBER(S) U1
v ❑DV
/2 0 0 5 Dodge Dakota 2011 00-NONE 0. Ql--0 DUE TO CRASH rg ❑ 2 x
0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
POINT OF 8 i1 A -4 COM VEH ❑ N U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .5 •)ryes.See Sidebar
ZWest Chicago IL 60185 0 1 0 3913916B IL 2026 I 0 N
Z
IL D 0 1 D7RW3G K3BS585734 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0157026-SFP BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER ui =
iUPIIT1 ISEATI (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 4 04 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 07,21 /2025 01 35 ®pm in a Work Zone? NCI N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
0 2 0 2 14 / / 0 PM ❑Construction
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
U2
-a, ARREST NAME Oranger.Jacob.T. 11-902 1540-286 / / ❑❑PM ❑Maintenance SLMT 1 1 1 ❑CITATIONS ISSUED SECTION CITATION
PENDINGUtilityMT
N NO. ROAD CLEARANCE TIME
o 0•
AM u, 35
t 2 ❑ ARREST NAME 07/21 /2025 02 25 M PM ❑Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1540-Allah. Muhammad 401 08 / 12/2025 01 30 ElPM ®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••--, ,
J
I ACMVdefinedasanytorvehleusedtotransportpassengersorpropeand: Z
1L.: 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' bra. INDICATE NORTH combination):or —I
I 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
- IIP'
} } } transporting employee In the courses of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
} } 1- •4. Is used or designated to transport between 9 and 15 passengers,including the driver. w
for direct compensation(example:large van used for specific purpose):or O
L L____a____.I I I . _ t i. i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
O1 CARRIER NAME
P _ ADDRESS
_or�ctcnmpata,m�i I D
rn
I
I
N ,
CITY/STATE/ZIP 0
_ MOTOR CARR.ID 0 Interstate 0 Intrastate
I Not To Scale 0 Not in Comm./Govt. 0 Not in Comm./Other 00
--- --1 I - i. USDOT NO. ILCC NO. C
m
8tIChadA4at 71
Source of above z
If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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
Black Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE