HomeMy WebLinkAbout2026-00003510 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0
fl 0 �0011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X110050
u, 1 U21 1 1 1 UI 8 U2 1 u, 1 U2 1 U, 1 U2 1 1 12 U, 13 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-0000351 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m® ❑ RELATED ❑Y ®N 01 18 2026 ❑AM ❑YES ®
PRIVATE NO U1
N MCLEAN BLVD Elgin mo /day/yr 12.05 ®PM FLOW CONDITION M
IXI 0 ® O COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Cl)
IXI_ !MI N E S W Larkin Ave WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
Hi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGED AREA(S) FRO TOWED U1 O
NAME(LAST,FIRST,M) Vijay-Chittan.S. 1 0 /
yr 13-UNDERCARRIAGE 10l !. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rn
M 2 4 ❑Y ®N SYSTEM
UNK VEH. AT CRASH 99-UNKNOWN 9 76•TOP 3 ,Detraction Value 9 ALGN •
2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s• i! a Il COM VEH 0 Ea 1 C)
" ~ Naperville I L 60563 0 1 0 AZ71262 I L 2026 FIRST CONTACT 5 T :REAR
_Q =uYes.See sidebar Ut
c Z
TELEPHONE
IL D 0 SFNRL5H41GB008770 Progressive ❑Y IglN U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 Same 95027 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
1 9 yf 3 Ford F250 2015 00-NONE O, Q1.O DUE TO CRASH ❑ !g 2 x
0 13-UNDER CARRIAGE FIRE 0 ® U2 C
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6-TOP 3 X
0 Y NJ 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.iI 6 i_i, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 11 Y , _5 •If Yes.See Sidebar
H ELGIN IL 60123 C 1 452170D IL 2302 I 0 C
IL D 7 1 FT7W2B64FED25806 Farmers ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 Matheson. Loretta. M. 191570831 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 11 06 /
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 U46 School District Black metal fence 01 ,18 /2026 12 07 ®PM 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 1475 LARK)N AVE ELGIN IL 60123 20 99 01,18 ,2026 12 07 PM
® • ❑Construction
Z 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
ARREST NAME • 01,18/2026 12 10 ®PM
o N 0 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
r 2 ® 39 3 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - 0 AM Workers present? ❑Y 30
434-McNamara.Shane 602 , , ❑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••--, ,
J
I I I L
ACMVdefinedasanytorvehicleusedtotransportpassengersorpropeand: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' _ r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
T,
_ 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
— —
< I- -- i
Larkln7Ave - }} } transporting employee in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
L L....a....� r 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
-) il I } } } •
for direct compensation(example:large van used for specific purpose):or
I : 8out17Mckeen7Blvd
' L...4..... I l I I L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
-U
placarding(example:placards will be displayed on the vehicle). m
0
hi g Not To Scale _
`v p q' CARRIER NAME Z
112
I ADDRESS '
` I >
N 0
l I CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 I USDOT NO. ILCC NO. C
XI
Source of above z
. • m
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
to
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
Silver Silver
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE