HomeMy WebLinkAbout2026-00056719 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111111111111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00056719 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 mST CHARLES ST El In 10:01
® ❑ RELATED ®Y 0 N 09 17 2026 ❑AM YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑MN ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
NT�TOWED U1
Shafi.Ahmed 1 1 /
yr 13-UNDER CARRIAGE 1U i 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 NI 2 m
M 2 SYTM 4 ❑Y ON ®UNK VEH. 9 AT CRASH 9 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a4 COM VEH 0 j$J 1 0
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Hudsin NY 12534 0 1 0 FIRST CONTACT 12 T_;---__Li-_-_5 *IIYes.SeeSidebar U,
Z FE20465 IL 2026 REAR
TELEPHONE
NY D 5NPET4AC4AH645011 NIA El ®N U2 I''I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Posey Griffen.Asaade Abd.S. NIA 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES ❑Nuv 0 Ixv 0 CIRCLE NUMBER(S) U1
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'1 9 9 0 Nissan Altima 2023 00-NONE O Ql-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
POINT OF 8 i1�I" 4 COM VEH 0 ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .5 •)ryes.See Sidebar
— Mount Prospect IL 60056 0 1 0 EW28841 IL 2026 REAR O C
IL D 1 N4BL4DW3PN418223 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same I LAA117043100 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 05 / M 2 3 0 1 0
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/ / #OCCS >
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/ / 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 09,17 ,2026 10 01 ®AM 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)
0 2 ❑ 23 28 , , ❑PM 0 Construction >E
Z 3 0 Dyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
- ®a, ARREST NAME Shafi.Ahmed 11-1204-B 1552000434 / , ❑PM
U 1 1 1 1 CITATIONS ISSUED 0PENDING -
oSLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME El AM• ❑Utility
t 2 El ARREST NAME Shafi.Ahmed 3-707 1552000435 09,17 ,2026 10 03 ®PM 0 Unknown work zone type U1 35
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1552-Thompson.Ahmad Rashad 401 393-Gutierrez 10 ,20,2026 01 30 0 PM Workers present? ®N U2 35
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 -<
i- ;.--__r-_--; INDICATE NORTH combination):or 531BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
1 ++ 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
ji I. I- I- transportingemployees in thecoursee of their em« pbym�ent(example:employee � X
�Y� . transporter sed or d usually nated to transehrt betweeicle or n 9 and r 15 passengers,
or
��___ -- !'�` °x�'r�t } } for direct compensation(example:large van used for specific purpose):ording the diver, O
_a .: u'*r I _ t i. i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—1
_ CARRIER NAME Z
ADDRESS
V)
Not To Scale ` N
II CITY/STATE/ZIP g
s _ i. i. i. i. 4. MOTOR CARR.ID ❑ Interstate 0 Intrastate
1 I r3..vsr ❑ Not in Comm./Govt. 0 Not in Comm./Other
� "Y""1 USDOT NO. ILCC NO. m
XI
Source of above z
. 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
co
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
White White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . 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