HomeMy WebLinkAbout2025-00057990 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011001 I0H
III ll 01000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003950310*
u, 1 U21 1 1 1 U116 U2 1 U, 1 U2 1 U, 1 U2 1 1 11 U, 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 8
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00057990 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 09 03 2025 ❑AM ❑YES ®NO U1 -<
N STATE ST Elgin mo /day/yr 03:23 ®PM FLOW CONDITION Ill
I 0 ®!MI N E OS W Schiller St COUNTY PROPERTY ❑Y M N DOORING Ely #OF MOTOR 0 SLOW 1 (/)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 4 n
Y N
0 7 /
yr �° ®
Kia Motors Co rte 2024 00-NONE 010 DUE TO CRASH ❑
13-UNDERCARRIAGE 10,1 2 FIRE 0 al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 M
F 2 4 ❑Y ®N
SYSTEM
❑UNK VEH. AT CRASHD 99-UNKNOWN 9 16•TOP 3 *Distraction Value 4 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S4 COM VEH 0 1� 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_:---___Li-__-_5 *II Yes.See Sidebar Ut
Z EF16181 IL 2025 E
TELEPHONE
IL D 0 3KPF24ADXRE704062 None ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same None 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 r uv 0 KCV 0 DV BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1
m
O FOR DAMAGEDAREA(S) FRONT TOWED Y N
�^ NAME(LAST,FIRST,M) Latif.Shahnawaz. D. 0 mo 9 �ay 1 9 yf 8 Honda Pilot 2006 00-NONE 'o,I t2 (,-2 FIRE DUE OCRASH 0 ® U2 2 C
.. 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 6 .t. 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 O7 ,�=Q)OS •)ryes.See Sidebar C
ELGIN IL 60123 0 1 0 DZ74575 IL 2025 IAR Si)0
IL Other 0 5FNYF18136B006440 Statefarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 011482SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 4 05 /
' D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 91 !J2 /25 03 23 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
1
2 0 28 43 91 /J2 /25 03 23 ®PM ❑Construction *
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
— ®a, ARREST NAME ROBLES. MONICA. M. 11-601 1556000058 91 /12 /25 03 28 0 PM
oSLMT
U 11 1 • 0 UtilityCITATIONS ISSUED PENDING -
o N El CITATION NO. ROAD CLEARANCE TIME AM
T 2 El ARREST NAME ROBLES. MONICA. M. 3-707 1556000059 91 112 /25 04 05 0 PM El Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1556-Sanchez.Jimena 501 388-Nelis 10 171 /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
ADDITIONAL UNITS FORMS.
r ----r••--, 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 -<
} }---_r__--; } INDICATE NORTH p3
i Icombination)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or
X
- ------I----; I transporting employeened to s inthe course 5 or fewer passengers
rhea emaployment nd operated
xample:employee
transporter} } }
transporter-usually a van type vehicle or passenger car):or co
} } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
Sahllbr?3t I for direct compensation(example:large van used for specific purpose):or O
L L____a____. \ L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
m
N placarding(example:placards will be displayed on the vehicle). ;p
Not To Scale I L a -
I i - CARRIER NAME Z
�_ � ADDRESS 0
D
fir. rn
■ 0
cITY�sraTF�zIP
U 1 - i. 4. MOTOR CARR.ID 0 Interstate ❑ Intrastate
N?state?St ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
:- ----------1 I -
USDOT NO. ILCC NO. C
m
Xl
Source of above 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?El❑ Yes II No 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE