HomeMy WebLinkAbout2025-00017038 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 101101100 lfl 0010 1
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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 El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00017038 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 03 17 2025 ®AM ❑YES ®NO U1
KI M BALL ST Elgin05:51
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W BROOK ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
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CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0
0 4 !
yr
Fleenor.Aubrey.A. Mazda 3 2015 00-NONE „. Q , DUE TO CRASH ® ❑
13-UNDER CARRIAGE FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0U2 5 M
F 2 SY4 ❑Y ElM®UNK VEH. 9 AT CRASH IN 9 15-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 �i COM VEH 0 j$J 1 0
" �- SOUTH ELGIN I L 60177 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes,See Sidebar U1
ZFB68953 IL 2026 E
TELEPHONE
IL D J M 1 B M 1 V76 F1218472 State Farm ❑Y ®N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Fleenor.Cody 3524519SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y 0 N 2 XI
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED O PEDAL ❑EWES ❑iiuv 0 Ncv 0 DV CIRCLE NUMBER(S) U1
/1 9 9 9 Hyundai Tucson 2020' 00-NONE ,t_' t2.._, DUE TO CRASH ❑ C 2
o 13-UNDER CARRIAGE 101 2 FIRE ID ® U2 C
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F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 09 16.70P 3 X
❑Y ❑N Egi UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I 6 i!,_ COM VEH ❑ ® Ut CO
FIRST CONTACT 9 O7 _, _6 •(ryes,See Sidebar C
ELGIN IL 60120 0 1 0 AXMZ-GS IL 2025 Si)
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same AUT700870688 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
KNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (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 ❑Y U2 Z
u 1 ® 11 1 03,17 l2025 05 51 ®❑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 0 05 15 , ) 0 PM 0 Construction *
Z 3 0 I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Fleenor.Aubrey.A. 11-601-Ax W483000327 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM U, 35
t 2 0 ARREST NAME 031 17 l2025 06 30 [0 PM ❑Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
483-Lynch, Miriam too 331-Ziegler , / ❑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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
f ( r 0
I.
1. Hasa rratingmore than pound (example:truck or truck trailer
1. Hasa weight 10 000 5 i
INDICATE NORTH combination):o -<
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I _ (example:shuttle or charter bus):or 0
L L.___A.._.-: designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
INot To Scale I transporter-usually a van type vehicle or passenger car):or C
L -----------; - I. 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
I for direct compensation(example:large van used fors specific purose):or
O
__ _ i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
� � placarding(example:placards will be displayed on the vehicle). XI
/
', CARRIER NAME Z
s 0
'a R;. _ __ ADDRESS D
CITY/STATE/ZIP 0
grtlYM
MOTOR CARR.ID 0 Interstate 0 Intrastate
- 0
I I T I 1°"`r"1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
I. --- --• - USDOT NO. ILCC NO. m
XI
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
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 Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE