HomeMy WebLinkAbout2025-00056929 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 4
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00056929 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
® ❑ RELATED 0 Y ®N 08 30 2025 ❑AM ❑YES ®
PRIVATE NO U1
N RANDALL RD Elgin mo /day/yr 02:52 ®PM FLOW CONDITION M
50 ® COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 cn
!MI N E S W Weld Rd WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
0 8 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 (E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 5 M
M 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHIN 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;ij 6 4 COM VEH 0 Ea 1 0
f. FIRST CONTACT 99 7 . , _5 *II Yes.See Sidebar U1
Z Schamburg IL 60193 0 1 0 AH88690 AZ 2025 Is
TELEPHONE
IL D 0 1 FON F6CYOJ DB80157 National General ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
4 99 U-Haul 2020631445 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
98 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑r uv 0 NCv ❑DV CIRCLE NUMBER(S) U1
1 9 9 7 Acura TLX 2021 00-NONE ,�_' 12 -_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE o 1 2 FIRE ❑ El U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I 6 i!,_ COM VEH ❑ ® Ut CO
FIRST CONTACT 8 O7 _, _5 •(ryes,See Sidebar C
WEST DUNDEE IL 60118 0 1 0 EE17062 IL 2025 I Si)0
IL D 0 19UUB6F50MA006688 Allstate ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
1 99 Same 811621041 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ / 1 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 81 /01 /025 02 52 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 28 06 / / ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
- U2
a, ARREST NAME Khan. Noman.A. 11-601 1556000055 / r ❑❑AM ❑Maintenance SLMT® 1 1 1 •
❑CITATIONS ISSUED PENDING MT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y
0 AM
T 2 ElARREST NAME 81 /01 /025 02 52 ®PM ElUnknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1556-Sanchez.Jimena 801 391-Jacobucci 10 , 71 /025 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
j I I I I L ADDITIONAL UNITS FORMS.
r ----r••--, , I I I I , 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----; I I I I ` combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
T,
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 w
Weld?Rd C
i- ...l. - - 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
i. i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires. --Nt placarding(example:placards will be displayed on the vehicle). XI
N I I I I I - _- CARRIER NAME Z
Not To Scalei. ADDRESS
?Ra I?Rd >
I� I~14! CITY/STATE/ZIP
l' I - 1 MOTOR CARR.ID 0 Interstate 0 Intrastate
' - T I I I I I ❑ Not in Comm./Govt. Not in Comm./Other
"---- --: - USDOT NO. ILCC NO. C
XI
Source of above z
If Yes,Name on placard O
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE