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HomeMy WebLinkAbout2025-00060263 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 011000 0110 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003967252 u, 1 u21 3 4 1 U, 3 U2 1 U199 U2 1 U, 1 U2 1 1 15 u, 1 U2 7 *P 0119* 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 El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00060263 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl ® ❑ RELATED ®Y 0 N 09 13 2025 ®AM ❑YES ®NO U1 -< SHALES PKWY Elgin11:37 _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W RT20 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 00 1 / yr Patel.Atul Honda CRV 2025 00-NONE ©1 >2 �/DUE TOCRASH ® ❑ 13-UNDER CARRIAGE 10. • 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 O m M 2 SYTM IN ENGAGE15-OTHER 5 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il 6 4 s *u Yes.See Sidebar u1 COM VEH 0 j$J 1 0 H 1 FIRST CONTACT 12 7_ ELGIN IL 60124 0 1 0 EW26622 IL ;Ismi- __ Z E TELEPHONE IL D 0 2HKRS4H71SH420415 StateFarm ❑Y ®N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Patel. Ramabhai 3623570-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 eu p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uv 0 1 9 6 5 Ford Fusion 2010' 00-NONE „ " 12 "_, DUE TO CRASH rg ❑ 2 o yr .- 13-UNDERCARRIAGE FIRE ❑ ® U2 c ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 9 ® U1 0 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ) ,-4 COM VEH FIRST CONTACT 10 Y��_,-_6 •If Yes.See Sidebar C ELGIN IL 60120 B 1 0 Q322929 IL 2026 I O C IL D 0 3FAHPOHA6AR110506 American Alliance ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same ILA-0768846-02 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (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 El N 1 ® 11 4 09,13 ,2025 11 37 0 pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 0 25 18 , / ❑PM ❑Construction * Z1EMS ARRIVED TIME 5 3 0 CITATIONS ISSUED 0PENDING SECTION CITATION NO. ❑AM ❑Maintenance U2 —a, ARREST NAME Patel.Atul 11-601 1540-346 , , ❑PM o u ® 11 4 �!CITATIONS ISSUED 0 PENDING - TIME 1Utilit SLMT o N SECTION CITATION NO. ROAD CLEARANCE AM' ❑ y t 2 0 ARREST NAME Patel.Atul 11-305-A 1540-345 091 13 r2025 12 20 ®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 1540-Allah. Muhammad 401 10 , 14,2025 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••--, , ; 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 -I :-; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or \ T, \ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O )it \ } } } transporting employees in the course of their employment(example:employee X transporter-usually a van Type vehicle or passenger car):or w�\ - } } } C 4. Is used or designated to transport between 9 and 15 passengers,including the driver. w1 1!.."'" - for direct compensation(example:large van used for specific purpose):or O L L____a____.I _ 3� — _ _ L i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires µ', _ -+erg--—-wow,m placarding(example:placards will be displayed on the vehicle). m 0 �t' , . CARRIER NAME Z /// A ADDRESS D dto NW'lb so.r._I CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z NARRATIVE( Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 ❑ 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 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 Silver Blue.Light u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE