HomeMy WebLinkAbout2025-00072374 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II
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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 ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ElOVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00072374 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 m
® ❑ RELATED ®Y 0 N 11 08 2025 ®AM ❑YES ®NO U1 -<
N RANDALL RD Elgin06:07
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W POINT BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
IgI AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEON. ❑EDUCE ❑NW ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Ary
a(LAST,FIRST,M) P mo
!2 0 0 4 Ford Transit Connect 2019 00-NONE „. Q 0 DUE TO CRASH ❑ VI E
13-UNDER CARRIAGE FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 O m
F 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF $ ;i� B �i COM VEH 0 0 1 0
FIRST CONTACT 1 7_:,--_;__S *IrYes.See Sidebar U1
Z Cary IL 60013 0 1 0 AP74941 IL 2025 REAR
TELEPHONE
IL D 0 1 FDYR2CM9KKA96703 Old Republic Insurance Co ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 A-Tec Ambulance Sery MWTB31351225 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMV 0 NCV ❑DV
!1 9 8 3 Nissan Juke 2012 00-NONE a i QI'-0 DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7� .5 •(ryes.See Sidebar
H E LG I N Z I L 60123 0 1 0 AP74941 I L 2026 REAR 0 N
M
IL D 0 J N8AF5M RXCT105581 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0355304-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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
N 1 ® 11 1 11 ,81 ,025 06 07 ®❑Pmm� in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 25 28 I ! ❑PM ❑Construction *
Z 3 ❑ Dyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Aitipamula.Arya 11-601 1540-375 / ! ❑PM SLMT
1$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility
N 45
t 2 ❑ ARREST NAME Aitipamula.Arya 11-306 1540-374 1 1+8) 1025 07 07 [�PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1540-Allah. Muhammad 502 12 , 91 /025 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
N?Rendett?Rd ADDITIONAL UNITS FORMS.
. 0
r ----r••--, , I ; A CMV is defined as any motor vehicle used to transport passengers or property and: )110
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�____r____; I ; _ 1.c Hasaor more than pounds(example:truckortruck/trailer -1 1 1. Hasa weight rating10 000
INDICATE NORTH Iron) p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
t X
-----I-----; , 1 . transporting mployeened to slIn the course passengers5 or fewer thir emplod yment example:employeener or X
I. } }
i_ <.___a__._; ( t4+ltt `� I.
4alsuosedordrter- esllnatedto trany a van type sport betweeicle or n9a dr15prisen rs,includingthedriver,
} } for direct compensation(example:large van used for specific purpose):or
L L.._-a-___.: r f jr4y — - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 71
2 placarding(example:placards will be displayed on the vehicle). XI
Ni� I A , , , , , CARRIER NAME Z
1 Not Tb ScereJ ADDRESST.
rn
1 , I
CITY/STATE/ZIP
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I r I 0 Not in Comm./Govt. 0 Not in Comm./Other 00
--- I 1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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
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
Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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 Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE