HomeMy WebLinkAbout2025-00074950 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0040431370`
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00074950 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED PRIVATE ❑Y ®N 11 21 2025 Ilk-AM ❑YES ®NO U1 —<
S MCLEAN BLVD Elgin mo /day/yr 03:10 ®PM FLOW CONDITION m
_
1 Q COUNTY PROPERTY ❑Y 21N DOORING El #OF MOTOR 0 SLOW 1 cn
® Ci/MI N E O,N Erie St WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
F'tf TOWED U1
Mohammed. Imran. K. Toyota Prius 2010 00-NONE ,, • 12 DUE TOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
101 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m
M 2 SY4 ❑Y ❑SNE®UNK VEH. 9 AT CRASH M IN D 9 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 iI 6 �i COM VEH 0 j$J 1 0
~ Hoffman Estates IL 60169 0 1 0 FIRST CONTACT 1 7_• -_5 *IIYes.SeeSidebar Ut
Z AV54509 IL 2026
TELEPHONE
IL D 0 JTDKN3DU7A0010843 Founders ❑Y ®N U2 19 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR M
Younis. Khizra ITIL230436 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
18 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 l V 0 DV
2 0 0 4 Jeep(after 198��riot 2014 00-NONE 012.._, DUE TO CRASH 0 ! l 2 x
0y Yr 13-UNDER CARRIAGE 10 I 2 FIRE 0 El U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1r.
6-TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:, COM VEH 0 ® U1 W
FIRST CONTACT 11 7�� _, _5 •If Yes.See Sidebar
ELGIN IL 60120 0 1 0 EJ82997 IL 2026 RE 4 ((I)
IL D 0 1 C4NJ PBB8ED853384 Direct Auto ❑Y J N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Cruz Benitez.Jose. L. PAIL001206319 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(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 /21 /2025 03 11 ®AM in a Work Zone? ®N DIRP co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U, 1 C)
T
o",
2 0 28 2 ) ) 0 PM• ❑Construction *
R 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Mohammed. !wan. K. 11-601-Ax W1525000798 / / El PM SLMT
S' N 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE • TIME • 0 Utility
AM
1 2 El ARREST NAME 1 1/21 /2025 ❑❑PM 0 Unknown work zone type U1 35
x T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
1525-NavE.Oscar 601 - / / ❑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.
r ----r••--, , I N A CMV is defined as any motor vehicle used to transport passengers or property and: Z
_Not TO somaz
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
` ` --I -' •— r INDICATE NORTH combination):or —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
I- <-----I----I —• Eri•Tt�! - transportinggemployeeo slin the course of 5 or fewer passengers
e e mplanoyment(example:employee a contract ner X
• } r } transportr-usually a van type vehicle or passenger car): r co
L 4. Is used or designated to transport between 9 and 15 passengers,including (I)
}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
1
} } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
-I
CARRIER NAME Z
_ ADDRESS 0
'!Li ` CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. rn
Source of above 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
White Gray
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 DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE