HomeMy WebLinkAbout2025-00055095 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
011011001 I0fl IV 11000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003934.538
u, 1 U21 3 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119*
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!or Tow Due To Crash
0 AMENDED YR 2025I 2025-00055095 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED 0 Y ®N 08 23 2025 IMAM ❑YES ®NO U1
N RANDALL RD Elgin09:35
_ _ g PRIVATE mo /day/yr ID PM FLOW CONDITION 1T1
FT!MI N E S W 190 EB EXPY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
r'tf TOWED U1 O
NAME(LAST,FIRST,M) mo
/1 9 7 2 Nissan Rogue 2020 00-NONE
13-UNDER CARRIAGE ,, !12 0OUE TO CRASH ® 0
) FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTHER TAL(ALL) 1U O DISTRACTED 0 ]SI U2 0 M760 M 2 8 ❑Y SYSNTEM
VEH. O ATCRASHD 0 99-UUNKNOWN 9 76•TOP�3 `DistractionValue ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s• iI S it®COM VEH 0 Ea 1 C)
F. FIRST CONTACT 2 7 _1L-t-OS '1ryes.See Sidebar U1 0
Z Lake in Hills IL 60156 C 1 0 V931369 IL 2022 REAR
TELEPHONE
IL D 0 JN8AT2MV1 LW105889 Allstate ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Patel. Rohit. N. 811819953 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑Dv
+2 0 0 4 Subaru Outback 2016 00-NONE ,�_"i Qr O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN ''OistractIon Value 0
POINT OF S i1 �i COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5
FIRST CONTACT 1 7�- -5 •If Yes.See Sidebar
REAR C
Z Carpentersville IL 60110 0 1 0 FA96098 IL 2026 0 Si)
D
IL D 0 J F1 GJAA65G H020895 NONE ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same NONE BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT? (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS),!TELEPHONE) (EMS) (HOSPITAL)
1 4 03 /
/ / UI 3 :A
D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 08,23 ,2025 09 37 ®❑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 C)
v 2 0 2 99 08,23 ,2025 09 37 0 pm. 0 Construction >F
R 3 o xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ®AM ❑Maintenance U2
-a, ARREST NAME Patel. Rohit 11-902 1512576 08,23,2025 09 38 ❑pM SLMT
o U1 ® 11 1 •igiCITATIONS ISSUED 0 PENDING N ® Utility
SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0
o t 2 ❑ ARREST NAME Patel. Rohit 11-305-A 1512575 08/23 ,2025 10 30 ❑PM 0 Unknown work zone type U1 45
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
1512-Juarez-Huichapan.Juan 900 10 ,07,2025 01 30 ®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----r-•--, , 1 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 —I
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} } ;-.-�i.1 r r (example:shuttle or charter bus):or 0
y I 3. Is designed tocarry15 fewerpassengers andoperated carrier
esg ora contract ne O
} A i Not To Scale J } } } transporting employees in the course of thir employment(example:employee
CO
L ---- — 1 } •transporter sed or usually
designated to transehrt betweeicle or n 9 and r 15 passengers,ssen rs,including the dryer. C
r } } for direct compenation(examp large van used for specific purpose):or
L L____a....� E 'GO
voitr I t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
(t-1,� . placarding(example:placards will be displayed on the vehicle). ;p
N r
�?i I - CARRIER NAME Z
ADDRESS
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
). If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spit 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
to
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
Gray Red
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE