HomeMy WebLinkAbout2025-00064661 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00398:143
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025512025-00064661 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
N GIFFORD ST Elgin 04:03
® ❑ RELATED ®Y 0 N 10 02 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W FRANKLIN N ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Qg3 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 n
RO T TOWED U1 Q
NAME(LAST,FIRST,M) `7
Chisht�- mo yr Mudassir.A. Toyota Camry 2011 00-NONE „ i" , DUE TO CRASH ❑ EN
13-UNDER CARRIAGE �a:l Z : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0THER 0U2 02 �T1
F 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 15-99-UUNKNOWN 9 76•TOP 3 *Distraction Value 1 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL 6 I,.4 COM VEH 0 E! 1 O
F- FIRST CONTACT 12 7 ;—, _5 *IIYes.See Sidebar U1
Z Glendale Heights IL 60139 0 1 0 EB78900 IL 2026 REAR
TELEPHONE
IL D 0 4T4BF3EK1 BR174451 State Farm ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3534131SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER X*
Refused ❑Y ® N 2 XI
Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 lily 0 NOV 0 DV
/1 9 9 3 Yr Nissan Altima 2014 00-NONE ,�_"i 12'-_, DUE TO CRASH 0 2
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPIr3 * X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistracuon Value 1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i & I,_.4 COM VEH 0 ® U1 CO
FIRST CONTACT 3 Yam•_, -5 •If Yes.See Sidebar C
Z SOUTH ELGIN IL 60177 0 1 0 ED39917 IL 2026 I 0 Si)
M
IL D 0 1 N4AL3AP6EN211065 Progressive Insurance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 971884645 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
{UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 03 /
LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
N 1 ® 11 1 10,02 /2025 04 03 ®AM in a Work Zone? ®N DIRP co
1 r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n
T
0
2 ❑ 28 2 / / 0 PM• ❑Construction
Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o1 ® 11 1 ARREST NAME Chishty. Mudassir.A. 11-901-A 1511393 / / ID PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
El AM
r 2 El ARREST NAME 10/02 /2025 04 00 ®PM ❑Unknown work zone type U1 25
2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 25
1511-Ayala. Roberto 300 10 ,28,2025 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 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
L L___-a____.: L L L ...._-..:_____� t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
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
Gray Gray
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE