HomeMy WebLinkAbout2026-00002875 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I001111010 III II 1111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X{ 1118r9*
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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 4
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00002875 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
RT20 El ❑ RELATED ®Y 0 N 01 15 2026 07:47 E�IAM ❑YES ®NO U1
Elgin PRIVATE mo /day/yr ❑PM FLOW CONDITION ITT
FT!MI N E S W LAMBERT LN COUNTY PROPERTY El ® N DOORING ICIy #OF MOTOR El SLOW 1 cn
❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD El STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 4 <
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16.TOP 3 ❑ _
❑Y ®N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
s 4 COM VEH 0 j$J
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1[a !i,_ 1 00
~ 0 9 0 FIRST CONTACT 12 7_; _5 *IIYes.SeeSidebar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
UNK ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 Same UNK 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 99 G0)
�{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
/2 0 0 9 Honda Accord 2016 00-NONE i1_"j Q�,-_, DUE TO CRASH 0 ❑ 2 73
0 13-UNDER CARRIAGE 19( l FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value 9
POINT OF 8 i1 1I 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B _.5 •If Yes.See Sidebar
m BARTLETT IL 60103 0 1 0 DL81121 IL 2026 REAR 0 N
IL D 0 1 HGCR3F07GA018254 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 Avila. Robert.J. 2322849-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
W 06 / M
m
/ / #OCCS D
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ElY U2 Z
N 1 CD 11 4 01 /15 /2026 07 50 ®❑PM in a Work Zone? ®N AM DIRP D
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1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 0
v T 2 0 25 2 / / ❑PM ❑Construction X
Z3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 8
-a, ARREST NAME / / ❑PM '
o N 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
50
t 2 0 ARREST NAME AM
T / / O PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 50
434-McNamara.Shane 401 / / ❑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- }--_-r-_--; I INDICATE NORTH combination):or
�
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - } (example:shuttle or charter bus):or 0
Not To Scale r
. A ; I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
i. } } } transporting employees In the course of their employment(example:employee 73
Q N— transporter-usually a van type vehicle or passenger car):or
L "x D 4. Is used or designated to trans rt between 9 and 15 ge ng C}-----}----; - } } } g po passen rs,including the driver,
: for direct compensation(example:large van used for specific purpose):or O
L L i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
r.Ire.n. placarding(example:placards will be displayed on the vehicle). Xi
. 1
•-.' CARRIER NAME Z
air G ADDRESS O
CITY/STATE/ZIP
1 I 1 1 1 1•
g
MOTOR CARR.ID ❑ IntersNotintaCotemm.lGaA. ❑❑ Not Intrastatein I I T I ❑ Comm./Other
o
----------- - USDOT NO. ILCC NO. C
m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 1 m
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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 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE