HomeMy WebLinkAbout2026-00001712 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil l III H IIII
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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 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00001712 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE 0 Y ®N 01 09 2026 12,— ®YES 0 NO U1 -<
S STATE ST Elgin mo /day/yr 06:04 ®PM FLOW CONDITION M
®75 ®!MI N E OS W Walnut Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRO T�TOWED U1 0Duckins.Cameron. E. 0 8 1
yr 13-UNDER CARRIAGE 10 1 I: 2 FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 9 SY8 ❑Y ❑STM NE®UNK VEH. 9 AT CRASH 9 99-UNK 15- NOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 4 COM VEH 0 j$J 1 0
F• Elgin I L 60120 B 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1
Z 9 FG71000 IL 2026 REAR
TELEPHONE
IL D 2T1 BU RH E9FC263331 Kemper insurance ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 12AU001538548 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph El El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEOAL 0 EWES 0 NMV 0 NOV 0 DV
2 0 0 3 Buick Envista 2025 00-NONE 11-.. 12 DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE ,IFIRE ❑ ® U2
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M 9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 916-TOPO3
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 I( 4 COM VEH 0 ® U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes.See SidebarC
H ELGIN IL 60123 A 1 0 FL13580 IL 2026 FIRST 0
IL D 1 G 1 ZD5ST4LF103951 Progressive ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Longley.Amy. R. 862600199 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME(!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 05 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 Laird Funeral Home Lamp post/bush 01 ,09 /2026 06 04 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
;, 2 0 43 3 310 S STATE ST ELGIN IL 60123 04 99 01,09 ,2026 06 04 PM
® • El Construction
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R O ❑ El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Duckins.Cameron. E. 3-707 S1552000264 01,09,2026 06 20 El pm• • El SLMT
ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 El ARREST NAME Duckins.Cameron. E. 11-703-A S1552000264 01 r 09 i2026 06 55 ®PM 0 Unknown work zone type U1 40
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El1552-Thompson.Ahmad Rashad 701 337-Thompson 02 , 17,2026 01 30 ®PM Am Workers present? ®N U2 40
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.
A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -<
C
c ' r INDICATE NORTH combination):or
' Not To Scale 'I~ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
ell I
- } (example:shuttle or charter bus):or
i i 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I- <.__-A-.-.� W� Ave g - y } } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including wwjt
-- -- I _ - } } g po pafic p rs,indudi the driver,
for direct compensation(example:large van used for specific purpose):or O
< i. < i. _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires` M
2 I t I t placarding(example:placards will be displayed on the vehicle). m
r M
A
CARRIER NAME
Z
II ADDRESST.
0
I O
CITY/STATE/ZIP C
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I sastrrt'r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- '-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 Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
Redmons . 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