HomeMy WebLinkAbout2026-00005606 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 100111101101111 I
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X123631
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00005606 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED PRIVATE ❑Y ®N 01 29 2026 ❑AM ❑YES El NO U1 —<
S MCLEAN BLVD Elgin mo /day/yr 12:31 ®PM FLOW CONDITION m
_
I0 ®!MI O E S W Fleetwood Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 3 /
yr 13-UNDER CARRIAGE 10:) 2 , 2 FIRE ❑ ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m
F 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 5 ALGN =
❑ ID N ID VEH. AT CRASH 99-UNKNOWN `Distraction Vatuc
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR0
F) FIRST
OF $ 1 a 4 COM VEH 0 El 1 0
FIRST CONTACT 12 7 . __5 *IrYes.See Sidebar Ut
Z Carpentersville IL 60110 0 1 0 EL32461 IL I ,
TELEPHONE
IL D 1G4HP54K1YU287680 State Farm ❑Y ®N U2 19 , m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Levesque. Kevin 3462360-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EWES 0 i uv 0 i v 0 DV
2 0 0 7 NT Volkswagen Jetta 2014 00-NONE 1("j 12--_1 DUE TO CRASH 0 !1 2 x
o 13-UNDER CARRIAGE 10'I !. 2 FIRE ID ElU2 C
Ti
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S :; COM VEH ❑ ® Ut CO
F„ FIRST CONTACT 6 O7 ,�=_Q�_5 •If Yes.See Sidebar
ELGIN IL 60124 0 1 0 V432101 ILaRC
0 cn
IL D 3VWD07AJ9EM437899 Foremost Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
McGuire. Dustin. L. A7997231150 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) {EMS) (HOSPITAL)
U2 996 r
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71
/ U1 1 D
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 ,91 ,026 12 31 ®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
0 2 ❑ 41 03 , ) 0 PM ❑Construction *
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME McGuire.Cole.A. 11-601 345000279 / ! El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
35
r 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
345-Gomoll.Geoffrey 701 31 , 01 ,026 09 00 0 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
�____r____; I ® ) combination)ghtratingmorethan10,000pounds(example:truck or truck trailer
�f 1. -<
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver(example:shuttle or charter bus):or C
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
- - . - . transporting employee in the course of their employment(example:employee X
unh 2 transporter-usually a van type vehicle or passenger car):or w
L }-----}. ..; \ ! - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
— for direct compensation(example:large van used fors specific purose):or O
-D
t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a placarding(example:placards will be isplayed on the vehicle).
' i —
uett
CARRIER NAME Z
'— _ ADDRESS D
Fleettwod?DrIve w
CITY/STATE/ZIP 0
0
_ MOTOR CARR.ID El Interstate El Intrastate
Not To Scale 1 0
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
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 M
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
71
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' M
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Maroon White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE