HomeMy WebLinkAbout2025-00001890 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets II III HH II11II Mil 01100 HuH
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00001890 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 01 09 2025 ®AM ❑YES ®NO U1 '<
N STATE ST Elgin08:49
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W TOLLGATE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 6 (n
❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Kelley.Sara. B. 1 0 /
yr 13-UNDER CARRIAGE IE
fal I•!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
F 2 SY15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 76•TOP 3 ,Detraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i s ;i 4 COM VEH 0 E! 1 C)
H Z Akron OH 44301 0 1 0 FIRST CONTACT 5 t.t _lo *If Yes.See Sidebar U1 0
JAL9115 OH 2025 REAR
TELEPHONE
OH D JTEAAAAH8NJ088739 Safeco Insurance Company ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same k3835243 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ uv 0 NOV ❑Dv
yr 12 _ C
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
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❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ailI 5 i.',_4 COM VEH ® ❑ U1 CO
FIRST CONTACT 11 7 L�1 �__5 •IfYes.See Sidebar C
ELGIN IL 60123 0 1 0 3170599 IN 2025 BAR 0 Si)
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IL B 7 2NKHHJ7X4KM248339 Liberty Mutual Fire Ins C ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Heritage Crystal Cle as2641445774034 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co
DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 01 r 09 /2025 08 49 ®❑PM AM in a Work Zone? ®N DIRP >
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
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2 20 99 1 1 ❑PM ❑Construction *
ry 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 6
❑AM ❑Maintenance U2
—a, ARREST NAME Kelley.Sara. B. 11-708 w1545-109 / ! ❑PM
® 1 1 4 UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o N 1 El
0CITATIONS ISSUED PENDING
AM u, 45
r 2 ❑ ARREST NAME 01+09 l2025 08 49 [M PM ❑Unknown work zone type
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1545 VanEycke. Brier 501 , ❑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
0 ADDITIONAL UNITS FORMS.
r -- r•"--, , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not To Scab f 1. sweightratingmore thanpounds(example:truck or truckrtratler -<
Has a10,000
-- combination):or
}_-_'r__ , I I .I r INDICATE
ARROW
.Zl
j I I I — 1 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
3. Is designed to car 15 or fewer passengers and operated a contract carrier O
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} } } transporting employees in the course of their employment(example:employee
ii transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C/ } } for direct compensation(example:large van used for speific purpoe):or
the driver.
•
L L____a....� � t i i. t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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•
D
,� � 22 placarding(example:placards will be isplayed on the vehicle). XI
_'�E� D
'' �� CARRIER NAME Heritage Crystal Clean Z
1 w .....2.:—......._:_______ 0
ADDRESS 1585 HIGH POINT DR D
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CITY/STATE/ZIP ELGIN 1 IL160123 n
II - MOTOR CARR.ID El Interstate ❑ Intrastate
I I T I El Not in Comm./Govt. 0 Not in Comm./Other 00
L --- --4I I - ii i. i. = USDOT NO 831633 ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD"; ❑Yes ®No =
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: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE