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HomeMy WebLinkAbout2026-00004100 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UH U� �� IlUU III ifi HHHHI1 11I1UU DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X 111954- u, 1 U2 1 1 1 U, 9 U2 U, 1 1_12 U, 1 U2 1 7 U123 U2 *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 ®5501-$1.500 ®ON SCENE 8 VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2026I 2026-000041 OO VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 -n 667 N STATE ST Elgin02:37 ® ❑ RELATED 0 Y ®N 01 21 2026 DAM ❑YES IX]NO U1 -< _ 9 PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y 0 N DOORING ❑y #OF MOTOR 0 SLOW Cl) ❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FRCPtf TOWED U1 Q Kenneth. R. 0 1 / yr 13-UNDER CARRIAGE ©i O!._2 FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 m M 2 SY is-OTHER 4 ❑Y EtM❑UNK VEH. 0 AT CRASH IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i:�—_s �i;_4 COM VEH ❑ j$J 1 O0 f. FIRST CONTACT 11 7_ _ _5 *ll yes.See Sidebar U1 Z Stone Mountain GA 30088 0 1 P1220311 IL 2026 REAR TELEPHONE GA Other 7 3AKJ H H DV6RSU R8229 Acord-Acrisure LLC ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Sikora Express 2094199928 3 m o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE.ZIP PHONE NUMBER RESPONDER 20 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 12 _ 71 o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0 0 Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:-6 COM•I sVEH See •Sidebar❑ 0 C CO F` ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YO❑N NDER U1 = (UNIT) (SEAT I (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 20 5 Swatchbox Stacked Drywall 01 ,21 /2026 02 37 ®PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ., v t 2 0 667 N STATE ST ELGIN IL 60123 30 14 ! ! ❑AM ❑Construction * Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME / / ID PM ' o u 0 CITATIONS ISSUED ❑PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit 15 y SLMT t 2 ARREST NAME AM 7 ! r ❑❑PM ❑Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ ❑AM Workers present? ❑ 487-Heal. Kayla 501 320-Cox , , ❑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 -< c ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (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 } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L i l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmt -I CARRIER NAME Z ADDRESS 0 V) 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ 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 . Were HAZMAT placards on vehicle? 0 Yes 0 No = 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE