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HomeMy WebLinkAbout2025-00005592 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV u, 1 U2 3 4 1 U1 1 U2 u, 1 1_12 U, 1 U2 1 10 U1 1 U2 *P 0119* 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 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202512025-00005592 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I DOUGLAS AVE Elgin 02:24 ® ❑ RELATED ®Y 0 N 01 26 2025 ❑AM YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W KIMBALL BALL ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR El SLOW Cl) ❑ Cook HIT ❑V ® N WITH VEHICLES INVLD El STOPPED U2 —I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROM TOWED U1 O NAME(LAST,FIRST,M) Cleinmark.Jennifer. R. mo1 1 / 1 9 yr7 6 Jeep(after 19680nd Cherokee 2020 00-NONE ©t. Qz ,�t DUE TO CRASH ® ❑ O 13-UNDER CARRIAGE ) 2 FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 23 U2 m F 2 SYST8 ❑Y IN NEM IN n❑UNK VEH. 0 ATCRASHH D 0 99-UUTHER NKNOWN 9 t6•TOP 3 `DistractionVatue 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a 4 COM VEH ❑ Ea 1 00 ~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Ir Yes.See Sidebar U1 Z 8519240 IL 2025 Ismi TELEPHONE IL 1 C4RJ FAG3LC343407 State Farm ❑Y Igl N U2 19 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 0420265-SFP-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row yr 12 _ C1 o 13-UNDER CARRIAGE t�.i t, FIRE 0 0 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 *Distraction Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-5 COM•I sVEH See •Sidebar❑ ❑ C CO F` ----- co 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 < RESPNDER❑YO❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m 71 / / UI 4 m 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 1 01 ,26 /2025 02 24 ®AM in a Work Zone? NJN DIRP co I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 0 T 0, t 2 ❑ ! / ❑PM• El Construction Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / ❑PM ' o N 1 ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,_,Utility SLMT 35 t 2 ARREST NAME AM T ! ! ❑❑PM ❑Unknown work zone type U1 El n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 475-Williarhs. Brianna tot 02 ! 11 ,2025 09 00 ❑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. 0 A CMV is defined as for vehxae used to tra and: r ----,5-••--, ; any mo nsport passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer T. } i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' J. , } (example:shuttle or charter bus):or X 3. Is L L.___A.. 1 i. <--_- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } • � . transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , < .---_-a-___� , J. , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.I L L L ...._-..i._ 1 t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zt --I CARRIER NAME Z i. ADDRESS 0 th CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . GVWR/GCWR m 0 <10,000 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI 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 73 IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m to 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 3 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BYITO. Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE