HomeMy WebLinkAbout2026-00002505 ILLINOIS TRAFFIC CRASH REPORT sheet 1 a2 Sheets II
III H
IIII UH U II IlU I II VlllUI 1111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X1141988
u, 9 U21 3 4 1 U1 3 U2 1 U1 99 1_12 1 1.11 99 U2 1 5 15 u, 1 U2 1 *P 0119*
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 ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00002505 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
DOUGLAS AVE El 08:16
® ❑ RELATED ®Y 0 N 01 13 2026 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W E CH ICAGO ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®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 2 n
! ! T FOR DAMAGEDAREA(S) FROM�TOWED U1 0Unknown.0. Unknown Unknown 00-NONE 0 >2 �/OUETOCRASH ❑ ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 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 ID N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
8 4
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 1, COM VEH 0 0 1
I— 0 9 FIRST CONTACT 12 7_: _5 * rYes,See Sidebar U1
0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
unknown ❑Y 0 N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N❑l N 0
m
N DRIVER ID PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ ivy 0 NOV ❑Dv
/1 9 6 7 Nissan Sentra 2013 oo-NONE 1(FRj t2..-_, DUETOCRASH 0 ❑ 2 73
o Yr - 13-UNDERCARRIAGE 1• FIRE 0 El U2
c
F 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPZ
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 6 �._ 4 O.OM VEH ❑ ® Ut CO
FIRST CONTACT 3 Y—�_,-_�O.
(ryes,See Sidebar C
E LG I N I L 60123 0 1 0 ES46318 I L 2026 REAR Si)0
Z
IL D 3N1AB7AP5DL682811 FIRST INSURNACE ❑Y 123 N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same HUGO 3632208 BAc $
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)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U2 m
##OCCS y
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
N 1 ® 11 1 01 /13 l2026 08 16 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP H .
AM U1
2 0 25 99
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING 1 1 ❑PM• ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
—a, ARREST NAME / / El PM '
1 ® 1 1 1 UtilitySLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
0 AM
t 2 ElARREST NAME 01/1 3 /2026 08 16 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 30
1535 Solis• Laura 101 337-Thompson / ❑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 combination):. Hasor more than pound (example:truck or truckrtrarler -<
1. Has a weight rating10 000 5
ID
INDICATE NORTH 531
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L.I .o Sole i _ (example:shuttle or charter bus):or
r r 3. Is d ned t carry 15 otr fewer passengers and operated a contract carrier O
A I l
esg o pa g pe
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or �
L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or o
L L____a.....l Unll 2 t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I'w{ii placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME —I
Ill Z
E ADDRESS o
CCITY/STATE/ZIPOC)
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 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
Black 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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE