HomeMy WebLinkAbout2025-00056763 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 8 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003943217*
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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 ❑5501-$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 202512025-00056763 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE 0 Y ®N 08 29 2025 ❑AM ❑YES ®NO U1 -<
BODE RD Elgin mo /day/yr 08:00 ®PM FLOW CONDITION m
02O C.'J!MI N E O W LONG FORD Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
STOPPED U2 '-I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
ti DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
1 1
yr 13-UNDER CARRIAGE 101 IE
!�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 Ea U2 m
M 2 8 El ®SNE❑UNK VEH. O AT CRASH IN ENGAGEO 99-UUNKNOWN 9 16-TOPO `Distraction Vales 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, it 6 �1 COM VEH 0 Ea 1 0
F. FIRST CONTACT 2 7_:11,-t-OS 'IrYes.See Sidebar U1 0
II'. STREAMWOOD IL 60107 C 1 0 EJ69363 IL 2026 REAR
TELEPHONE
IL D 0 JN1 EV7ARXHM832465 UNISURED ❑Y ❑N U2 Mr-
la
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same UNISURED 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
yr ,2 - C
.0 13-UNDER CARRIAGE 10.i :. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 `Distraction Value 2 -
-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA-d:-5 CCO
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
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Pj
/ / UI 1 D
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EV MOST DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 0 1 2 ComEd telephone pole snapped 08,29 ,2025 08 00 0 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
1 2 ® 31 2 1300 SPAULDING RD ELGIN IL 60120 28 20 08,29 ,2025 08 09 ®PM ❑Construction F
R O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ❑AM ❑Maintenance U2
-a, ARREST NAME Hussaini. Musa. K. 11-502.15- 1551-000193 08,29 r2025 08 15 Igi pM SLMT
o u 1 0 ig!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility
t 2 0 ARREST NAME Hussaini. Musa. K. 11-601 1551-000194 08129 r2025 08 49 ®pM ❑Unknown work zone type U1 35
n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1551-Dede.Joseph 202 391-Jacobucci 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 truckrtrailer -<
i_ i.. -:. j I 7
i- }---_r----; INDICATE NORTH combination):or
—
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
— — — — transporter-usually a van type vehicle or passenger car):or CO
L I.
4. Is used or designated to transport between 9 and 15 passengers,including N
-- } } } g po passen rs,includi the driver,
i for direct compensation(example:large van used for specific purpose):or O
L L____a____. I l. i. i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
placarding(example:placards will be displayed on the vehicle). ,Zmt
II CARRIER NAME Z
ice.,
[swam 1 ADDRESS 0
(
ICITY/STATE/ZIP C
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __, - USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD"; ❑Yes 0 No =
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
a
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Artier/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO T6 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE