HomeMy WebLinkAbout2025-00067148 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III 11 IIII
OUI 01100 III ID OU000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40399C868
u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 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 ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00067148 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
176 RT20 WB El In08:45
® ❑ RELATED ❑Y ®N 10 14 2025 ®AM D YES ®NO U1 '<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Y RUN&
Cook HIT ❑ ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES ❑uuv ❑!Cy 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 1 n
.FROM O
Doll. Diontae.J. Honda Accord 2000 00-NONE 11 T TOWED EN E
U1 12 DUE TOCRASH ❑
IE
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ❑ 0U2 1 M
M 2 4 SYTM❑Y ®NNE❑UNK VEH. O ATCRASHD 0 15-99-UUNKNOWN 9 76•TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI S �i 4 COM VEH 0 j$J 1 0
" �- SOUTH ELGIN N I L 60177 0 1 0 FIRST CONTACT 1 7 : __5 *If Yes.See Sidebar Ul
ZCF32896 IL 2026 E
TELEPHONE
IL D 0 1 HGCG1645YA058671 Progressive ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 903216312 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
m E{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 NMV 0 NOV 0 DV
!2 0 0 8 Subaru Ascent 2019 00-NONE 'o,I t2 (,-2 FIRE DUE ID
CRASH rg ® U2 2 C
o Yr 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 1(,_
*Oistractlon Value 0
POINT OF 8 It 4 COM VEH ❑ ® Ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 Q _,=:_ ((Yes.See Sidebar 5 •
BARTLETT IL 60103 0 1 0 Q792124 IL 2026 REARO
IL D 4S4WMACD6K3434844 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Mohammed.Safia 2716374-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 0 5 /
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 10,14 l2025 08 45 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)
o"
2 28 99 I ! 0 PM, ®Construction >E
Z 3 0 1!>I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 El 11 1 ARREST NAME Doll. Diontae.J. 11-601-Ax 1547000149 ! ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
AM 45
r 2 ElARREST NAME 10 r 14 l2025 09 14 [M PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? Y 45
1547-Steele.Justin 401 11 ,04,2025 09 00 ❑PM 0—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 e-----e••--, , ; 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 -<
` ` -' -' r INDICATE NORTH combination):or —I
A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
N Not To Scale 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 -----}----; l - } } } 4. Is used or designated to transport between 9 and 1 passen rs,including the driver,
C
f for direct compensation(example:large van used fors specific purpose):or
L L 1 t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
;0
- T "� '"n CARRIER NAME Z
— — —
ADDRESS
r_.t unto D
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;•--------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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 VIM 1 m
to
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
Gold White
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE