HomeMy WebLinkAbout2025-00056218 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 Hill 001 II 11 0
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00056218 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 08 27 2025 DAM ❑YES ®NO U1 -<
BUSHWOOD DR Elgin03:45
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W NORTHWEST PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DOSTOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NIA/ 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) Mao TOWED U1 Q
NAME(LAST,FIRST,M)
RAH MAN.SHAN H NAZ.A. mo !1 9 5 9 Lexus ES350 2020 00-NONE it t2 , DUE TO CRASH 0
13-UNDER CARRIAGE 101 •�. FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 2 m
M 2 SYTM IN ENGAGEDTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 9 16-TOP® `Distraction Value 9 ALGN =
1• CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i, 6 �I COM VEH 0 j$J 1 n
" �- LAKE I N THE HILLS I L 60156 0 1 0 FIRST CONTACT 4 r i -� •II Yes.See Sidebar U1 0
Z CH22292 IL 2025 E
TELEPHONE
IL D 0 58AGZ1 B17LU082231 STATE FARM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 2862655-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 l uv 0 e v 0 Dv
!1 9 8 0 Honda Civic 2015 00-NONE ,._"1 R2Qi O DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 16) I 2 FIRE 0 El U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_i 6 1�_4 COM VEH ❑ ® u1 CO
FIRST CONTACT 12 7._�_, =5 •If Yes.See Sidebar C
E LG I N I L 60120 0 1 0 BQQ94385 I L 2026 I:EaR 0 Si)
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IL D 0 19XFB2F52FE102063 PROGRESSIVE INSURANCE ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 951634811 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
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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 0 Y U2 Z
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N 1 El 11 1 08,27 /2025 03 45 ®pm in a Work Zone? ®N DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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2 0 2 28 , , 0 PM- ❑Construction *
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM El Maintenance U2
a RAH MAN.SHAN H NAZ.A. 11-601 1551-000184 / , PM
-' 1 21 1 1 1 ARREST NAME ❑
o U ig!CITATIONS ISSUED 0 PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM, ❑
t 2 ❑ ARREST NAME RAH MAN.SHAN H NAZ.A. 11-901 1551-000183 08/27 l2025 04 00 ®PM ❑Unknown work zone type u1 30
2 2 3 0 -
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1551-Dede.Joseph 901 269-Mendiola 10 , 14,2025 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 -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} 0 _ i. (example:shuttle or charter bus):or 0
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< ------;----: I I transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employeener X
r I ? 'J Not To Scale 1 } transporter-usually a van type vehicle or passenger car):or co
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} } 1 4. Isusedordesignatedtotransportbetween9and 1�ssen includingthedriver. y
I for direct compensation(example:large van used fors specific purpose):or
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__ _ t l. I I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESS 0
unites I 1 Ella w
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
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Source of above z
. IDOT PERMIT NO. WIDELOAD"; 0 Yes 0 No 2
TRAILER VIN 1 m
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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
White Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE