HomeMy WebLinkAbout2025-00071513 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004016048
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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 ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED IDB Injury and f or Tow Due To Crash YR 2025512025-000715513 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 21 �I
® ❑ RELATED ❑Y ®N 11 03 2025 ®AM ❑YES ®NO U1
GIFFORD RD Elgin 07:56
_ _ g PRIVATE mo /day/yr ID PM FLOW CONDITION m
FT l MI N E S W BLUFF CITY BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NIA/ 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0FOR DAMAGEDAREA(S) FROM TOWED U1 0Del ado Arista. Miguel.A. 0 3 /
yr
13-UNDER CARRIAGE i FIRE 0 IE
10• : 2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 1 M
M 2 4 SY❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il_S I, 4 COM VEH ❑ El 1 O
~ Hanover Park IL 60133 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.SeeSidebar IA
Z 4002157B IL 2026
TELEPHONE
IL D 0 1 FTSF3B56AEB25672 No Insurance ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same N/A 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER X*
Refused ❑Y ® N XI
24 c
x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 NAV 0 KV 0 DV
/1 9 yf 1 Subaru Forrester 2025 100 3-NONE 'o,I t2 (,-2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9!1,6•TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *0istraetlon Value 9 0
POINT OF 8 i` 4 COM VEH D ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 Q -5 •IT Yes,See Sidebar
BARTLETT IL 60103 0 1 0 SLVRLC1 IL 2026 I 0
IL D 0 JF2SLDDC5SH437736 AllState ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 923622698 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)l(ADDRESS)1 TELEPHONE) (EMS) (HOSPITAL)
1 3 09 /
/ / UI 3 :A
m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 ,03 /2025 07 56 ®❑pM in a Work Zone? ®N DIRP co
1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 03 18 / / 0 PM 0 Construction *
oG
R 3 0 ]� 5 CITATIONS ISSUED 0PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
-a, ARREST NAME Delgado Arista. Miguel.A. 3-707 1540-373 / / ❑PM SLMT
1 ® 1 1 1 CITATIONS ISSUED 0PENDING Utility
ran lTNSECTION CITATION NO. ROAD CLEARANCE TIME AM 0
o T 2 El ARREST NAME Delgado Arista. Miguel.A. 11-710-A 1540-371 11/03 /2025 09 00 M PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1540-Allah. Muhammad 401 12 ,09/2025 01 30 El NI ®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
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
• i.-- -i-- --; } } } r -, , ; ; , 1, ( 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
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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
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
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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
Green Green
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE