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HomeMy WebLinkAbout2025-00020450 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 V 1111 f IOU IOU DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003772025 u, 1 U21 3 4 1 U, 3 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00020450 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME WEST BARTLETT RD ElginSECONDARY CRASH 2 ® ❑ RELATED ❑Y ®N 04 01 2025 ®AM ❑YES ®NO U1 -< PRIVATE mo /day/yr 08.13 ❑PM FLOW CONDITION m _ 25COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 21 (n ® FT/� NOS W Gifford Rd WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED U1 0Jenkinson. Bryan. M. 0 1 / yr 13-UNDER CARRIAGE ©, :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m M 2 SYTM IN ENGAGE5 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S 4 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7_ �; _,__S *IIYes.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 1726069B IL 2026 REAR TELEPHONE IL D 0 1 FTFX1 CF4BFD23575 Liberty Insurance ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m M KD Electric inc AS7Z91477583035 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 21 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV 9 8 7 General Motore7. c41p 1998 00-NONE 10 t2 c,�2 DUE O CRASH 0 ® U2 24 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•TtOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN i `Oistraglon Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-.I�1:,-4 COM VEH El ❑ U1 CO FIRST CONTACT OO 7A' _.5 •If Yes.See Sidebar ELGIN IL 60120 0 1 0 33164K IL 2025 I 0 C IL D 0 1 G DJ7H 1 JOWJ511650 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BTR Landscaping J967561-a19-13 SAC E 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)I(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 BTR Landscaping Flattbed trailer 41 ,12 ,25 08 13 ®❑pM AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) v 2 0 36 ASH ST 60110 28 99 41 !12 ,25 08 14 ❑PM 0 Construction >E R 3 0 gi CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z J ®AM 0 Maintenance U2 a ® 11 1 ARREST NAME Jenkinson. Bryan. M. 11-601 1552000026 41 !12 r25 08 24 ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility AM 40 T 2 0 ARREST NAME 41 !12 125 08 47 MPM 0 Unknown work zone type u, 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 40 1552-Thompson.Ahmad Rashad 401 51 ! 01 l025 01 30 El 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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` --I -' I. INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n _ } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } IL - } transporting employees in the course of their employment(example:employee X " " i I transporter-usually a van type vehicle or passenger car):or coI- I- --I-----; We&t?Bartiett?Rd I - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or _ _Unit 1_ Unit 2 L L____a____ l� - - - - _ l. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XIw I , —I 0 I CARRIER NAME Z c I _ ADDRESS B- 1 Not TO SOON, j • • W a I CITY/STATE/ZIP I 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- ---'1 - USDOT NO. ILCC NO. rn XI Source of above Z . • m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes ® 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'7 0 Yes ®No 2 TRAILER VIN 1 16VDX1421 K5036417 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ® 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 14 ft. 2 ft. Z Blue White u 1 TOWED TOTAL VEHICLE LENGTH 14 ft. NO.OF AXLES 2 DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Unknown . 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. 4 CARGO BODY TYPE 4 LOAD TYPE 2