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HomeMy WebLinkAbout2026-00005458 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0011110110111000100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 04123213 u, 9 U21 2 4 1 U199 U2 1 U,99 u2 1 U,99 U2 1 4 15 u, 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202612026-00005458 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n N SPRING ST El In 05:32 ® ❑ RELATED ®Y 0 N 01 28 2026 ❑AM CI YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W PLUM ST COUNTY PROPERTY ElY ® N DOORING ICIy #OF MOTOR NI SLOW 1 (n ❑ Kane HIT ®Y El N WITH VEHICLES INVLD El STOPPED U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) &RUNPEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRCt4r�TOWED U1 0 Unknown.0. Nissan Pathfinder 2006 00-NONE ©, >2 �/DUE TOCRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 0 < M 9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 916.70P 3 ❑ _ ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 '�.4 C.OM VEH 0 j$J 1 0 0 9 0 FIRST CONTACT 12 7_; __5 *uYes.SeeSidebar Ut Z FJ27169 IL 2026 E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 -0 5N1AR18U86C666906 NIA ®Y ❑N U2 1-- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Dismuke.Andrea.S. NIA 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 99 x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 NCv ❑DV !1 9 y 70 Jeep(after 198��riot 2016 00-NONE „ " OM i-_, DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 I .�,.4 C.OM VEH ❑ ® tit CO FIRST CONTACT 11 7 _, _5 •IfYes.See Sidebar C ELGIN IL 60120 0 1 0 EF55658 IL 2026 Si)0 Z IL D 0 1 C4NJ RFB2G D654453 Statefarm ❑Y ®N RDEF P3 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 2152797-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER ut = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 01 ,28 ,2026 05 32 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 0 28 23 N 1 3 0 0 CITATIONS ISSUED ID PENDING + ) ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME ! r El PM ' oN 1 El 11 4 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,...,Utility SLMT r 2 ❑ ARREST NAMEAM 7 / / ❑❑PM ❑Unknown work zone type 05 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 30 1556-Sanchez.Jimena 102 , ❑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----; - combination):or N INDICATE NORTH p3 BY ARROWi. 2 Is used or designed to transport more than 15 passengers including the driver C - - Not To Scale „,�„a,� (example:shuttle or charter bus):or X L A l I ' 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O • - } } . transporting employees in the course of their employment(example:employee y a van type L ...l. t 4alsuosedordrter- �llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,indudirg[hedrwer, I w C „mai t } } for direct compensation(examp large van used for specific purpose):or N < .i. -11° I 1= - < I. < t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires III I I m placarding(example:placards will be displayed on the vehicle). ;p ' -1 . _ . CARRIER NAME Z ADDRESS 0V) O CITY/STATE/ZIPC MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 USDOT NO. ILCC NO. m XI Source of above 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 Blue,Dark Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE