HomeMy WebLinkAbout2026-00005230 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets IIIIII 11 IIII
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004123235
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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 ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00005230 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH m® ❑ RELATED PRIVATE ❑Y ®N 01 27 2026 ❑AM YES ®NO U1 —<
S STATE ST Elgin mo /day/yr 07:20 ®PM FLOW CONDITION m
_
®25 ® O COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
!MI N E S W Dana St WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS PED ❑PEDAL ❑EWES ❑uuv ❑/Cv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 8 /
yr 13-UNDER CARRIAGE 10 2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 35 M
M 1 SYSTEM IN ENGAGED 15-OTHER 9 le-TOP 3 _
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN a lL a Ii COM VEH 0 0 0
4 `Distraction Value ALGN
r POINT OF CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _•,F. FIRST CONTACT 00 7 -1 _5 *Irves.See Sidebar U1 0
Z ELGIN IL 60123 B 1 0 REAR
TELEPHONE
IL D 0 ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 62 1 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER Ai
Provena St.Joseph ❑Y ® N
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 row 0 KCV 0 DV
1 9 yf 2 Ford Bronco 2024 00-NONE 0.' t2'"_, DUE TO CRASH 0 2 x
0 13-UNDER CARRIAGE 19 I 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i 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 �1:, 4 COM VEH D ® U1 CO
FIRST CONTACT 11 TA _5 •If Yes.See Sidebar
z SOUTH ELGIN IL 60177 0 1 0 ET27938 IL 2026 REAR 0 C
IL D 0 3FMCR9C6ORRE44530 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
62 1 Same 0308404-SFP-13 SAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CD 12 1 01 /27 /2026 07 20 0 AM in a Work Zone? ®N o1RP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES Check one below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0
57 2 99 99 01l27 /2026 07 20 PM
® • ❑Construction >F
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
ARREST NAME 01/27/2026 07 26 ®PM
1 ® 12 2 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o u2. El
®AM U1
t 2 ❑ ARREST NAME 01/27 /2026 07 37 PM ❑Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 05
1544 Solis•Yulissa 982 / / ❑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 -' I. INDICATE NORTH combination):or —I
'''',g tillBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C(example:shuttle or charter bus):or C
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} I• . transporting employees in the course of their employment(example:employee X
I transporter-usually a van type vehicle or passenger car):or C
-- -- - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or 0
__ __ ii i _ t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). D�� II
CARRIER NAME Z
_ __ ADDRESS O
CC)
Not To Scale CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I. --- --• - USDOT NO. ILCC NO. m
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
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
Gray
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 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE