HomeMy WebLinkAbout2025-00071092 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0040250J6
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00071092 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 11 01 2025 ®AM ❑YES ®NO U1 -<
BIG TIMBER RD Elgin mo /day/yr 06:09 ❑PM FLOW CONDITION m
02040!MI N E O W Todd Farm Dr COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 3 /
yr 13-UNDER CARRIAGE 10 i !:. 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SY4 ❑Y ONM❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a 4 COM VEH ❑ j$J 1 0
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ELGIN IL 60120 0 1 0 FIRST CONTACT 99 7_; __5 *IIYes,SeeSidebar U1
Z EY44141 IL 2026 REAR
TELEPHONE
IL D 0 5YFB4MCE5SP225244 Bristol West Insurance ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same G01311609404 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KCv 0 DV
yr 12 _ C1
o 13-UNDER CARRIAGE 10.i t, 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-9 COM•I sVEH See •Sidebar❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 1 11 !01 l2025 06 09 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
ai 2 ❑ 36 2 21 99
t ! ! ❑PM ❑Construction *
Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME ! ! - ID PM
o N 1 ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ElUtility SLMT
AM
t 2 El ARREST NAME 1 1!02 12025 ❑❑PM ❑Unknown work zone type U1 45
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7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 1540-Allahi. Muhammad 501 331-Ziegler ! , 0 AM Workers present? ®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 truckrtrailer -<
} } ' ' " w!°N° I. INDICATE NORTH combination):or A
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
X
A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees in the course of their employment(example:employee P3
I transporter-usually a van type vehicle or passenger car):or co
' . 4. Is used or designated to transport between 9 and 15 passengers, rig rCjt
}--- ----J. I a - } } } g po passen rs,including the driver,
y for direct compensation(example:large van used for specific purpose):or O
L L____a____. -- -,n,,_ — — —r++—— — — — L . _ 5 Isvehiclesedtotrans transporthazardousmateral(HAZMAT)that requires
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eiyrnnarrnm ( tt� - anyW any Q
placarding(example:placards will be displayed on the vehicle). ;p
I I I I _, �� 2#
. .
t � ...___=_ I CARRIER NAME Z N
.. _ L �____.'. ADDRESS
1Voo To stet. ' • , • , D
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
PCI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
71
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQ No El Unknown Unknown 0
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' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE