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HomeMy WebLinkAbout2026-00002278 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIII DIII 0011 II ID 11111 10100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004107975 u, 1 U21 3 4 1 U1 4 U2 1 U, 1 1_12 1 U, 1 U2 1 4 11 u1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2026I 2026-00002278 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71 ® ❑ RELATED PRIVATE ®Y ❑N 01 12 2026 ❑AM ❑YES ®NO U1 -< BIG TIMBER RD Elgin mo /day/yr 05:14 ®PM FLOW CONDITION m _ ®25 FT/� NOS W Madeline Ln COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 183 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 2 n NT�TOWED U1 0NAME(LAST,FIRST,M) mo yr Erickson.Adam. R. Ford Transit Connect 2025 00-NONE ©, >.4:12 �/OUETOCRASH ❑ EN 13-UNDER CARRIAGE 1U 1 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. AT CRASHD 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i a ;} COM VEH 0 El 1 0H Z WEST DUNDEE IL 60118 1245 0 1 0 FIRST CONTACT 11 a'AV__s *II Yes.See Sidebar U1 0 FP327888 IL 2026 REAR TELEPHONE IL D 0 1 FTBR1X85SKB25406 Liberty Mutual Insurance ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 EAN Holdings.Christian.S. 016227420 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 21 (,�j x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 Dv CIRCLE NUMBER(S) U1 1 9$7 Hyundai Santa Fe 2022 00-NONE 'o,� t2 (,-2 DUE TO CRASH ® U2 2 cXj o 13-UNDER CARRIAGE FIRE 0 c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 POINT OF s it 1,:,,,C.OM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -.{ 6 FIRST CONTACT 5 7�_ s •IfYes.See Sidebar Z G I LBERTS IL 60036 C 1 0 EW45592 IL 2026 REAR IL D 0 5N MS2DAJ7N H469434 Progressive ❑Y 123 N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 387947752 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 1 11 (21 )026 05 39 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) ai 2 0 1 3 28 18 / / ❑PM• ❑Construction * Z3 0 'xi CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 a ® 11 1 ARREST NAME Erickson.Adam. R. 11-601 1560000284 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM T 2 ElARREST NAME 11 (21 1026 06 05 ®PM 0 Unknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1560-Jones. Bennett 901 21 , 12 (26 09 00 ❑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 truckrtrailer -< ` ` --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 i_ Not To / + - i. (example:shuttle or charter bus):or 0 Scale I 1 3. Is des ned to car 15 or fewer` A g ry passengers and operated by a contract career 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____� C 4. Is used ordesi natedtotrans rt between 9 and 15passengers,includingthedriver, I IN } } } for direct compensation(examp large van used for speific purose):or 0 L L____a____� erpannvmme. . t l. I. 1 _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires •u Iiirdj placarding(example:placards will be displayed on the vehicle). ,Zmt —1 unIrei unaer CARRIER NAME Z ADDRESS 0 w C) 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. - --1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 White Gray 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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE