HomeMy WebLinkAbout2026-00004143 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets II III 11 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004112249
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00004143 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
438 VILLA ST Elgin06:00
® ❑ RELATED ❑Y ®N 01 21 2026 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Ch
❑ FT/MI NESW 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 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
! / FOR DAMAGEDAREA(S) hrr TOWED U1
Unknown.O. Unknown Unknown 00-NONE „ R'O12 i 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 0 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction value ALGN =
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[S !i,_ 1 0
I— 0 9 9 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
Unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
ca
99 9 Same Unknown 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 99
m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 NCv ❑DV CIRCLE NUMBER(S) U1
!1 9 8 3 Dodge Ram 1500(van) 2021 00-NONE 13-UNDER CARRIAGE ,�_FR"j 12 -_, DUE TO CRASH 0
Cgl
I c FIRE 0 21 u2 2
10' 2C
0
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
I" 4 COM VEH ❑ ® U1 CO6
FIRST CONTACT 7 O8 7 j _� _s •If Yes.See Sidebar
Itasca IL 60143 0 1 0 141752C IL 2026 REAR 0 Si)
IL D 0 3C6FRVJGXME501247 Greenwhich ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Amazon RAC943896 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)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CO 11 9 01 /21 /2026 06 15 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 99
N 3 0 0 CITATIONS ISSUED 0 PENDING / / 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 2
z
—a, ARREST NAME / / ID PM '
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLAT
r 2 ❑ ARREST NAME DAM
T / / ❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1512-Juarez-Huichapan.Juan 300 320-Cox ! / ❑❑PM AM Workers present? ®N U2 30
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
r if) - combination): r more than pound (example:truck or truck/trailer
1. Has a weight rating10 000 5 -<
INDICATE NORTH o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC
- } (example:shuttle or charter bus):or
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} -A----i Not To Scale F - } } } transportingemployees in the course of their employment
(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L -a- - 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
L____a____. N. i i ._ 5. Is any vehicle used to transport hazardous material(HAZMA that requires
any -u
\ 'I placarding(example:placards will be displayed on the vehicle). XI
�N;..' _ - CARRIER NAME Z
‘/4.6 - ADDRESS 0
\ C
CITY/STATE/ZIP 0
- MOTOR CARR.ID 0 Interstate El Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; - USDOT NO. ILCC NO. m
XI
Source of above z
. 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'; 0 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
Blue
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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE