HomeMy WebLinkAbout2026-00002623 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IM UH UU II IlU
I 00110111000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X6C14108056
u, 9 U21 1 1 3 U, 8 U2 1 U1 99 1_12 1 1.11 99 U2 1 1 11 u, 13 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 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 ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash
0 AMENDED YR 202612026-00002623 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m® ❑ RELATED ®Y 0 N 01 14 2026E�IAM ❑YES E)PRIVATE NO U1
NESLER RD Elgin mo /day/yr 08:38 ❑PM FLOW CONDITION m
I0 ® COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
!MI N E S W South St WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J V ElN PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
yr 13-UNDER CARRIAGE fa !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 <
9 9 Y ❑N ®UNK VEH. AT SYSTEM IN 9
❑ ENGAGED CRASH 9 15-OTHER
99-UNKNOWN 9 76.TOP 3 ❑ _
a 4 `Distraction Vatuc ALGN
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iIn O1 0
C. VEH 0 ZgJ n
0 9 0 FIRST CONTACT 5 7_; -;_ 5 =IIYes.See Sidebar U1
C Z RFAR E
_ -I TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
unk ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same unk 3 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
� 1 9 8 2 Chevrolet Equinox 2013 00-NONE 0. Q!'-O DUE TO CRASH rg D 2 73
0 13-UNDER CARRIAGE 10( l 2 FIRE 0 ® U2 C
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 �1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7� , .5 •(ryes.See Sidebar
H ELGIN IL 60124 B 1 0 P485150 IL 2026 REAR
0 Z
IL D 0 2GNALBEKXD6250979 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 985778001 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER Ui _
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CO 11 9 01 ,14 i2026 08 38 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 20 11
N 3 0 0 CITATIONS ISSUED 0 PENDING + ) ❑PM• ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
AM45
Ti 2 El
r ❑❑PM 0 Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
348-Rapacz,Jordan 801 — r i ❑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.
8.. .. , tV A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r• -, o 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
c --I -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ ri } (example:shuttle or charter bus):or 0
Nesler Rdr1 = " 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
r
L- -A- --' V r 1 i. } } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
C
L }-----}----; • •
- I. } } •4. Is used or designated to transport between 9 and 1 passengers,including the driver,
for direct compensation(example:large van used fors specific purpose):or to
i ~ O
_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmj
-- —1
CARRIER NAME Z
__ ADDRESS 0
o
South St. CITY/STATE/ZIP E
- i. 4. MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 Not TO Scale ti ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 USDOT NO. ILCC NO. m
XI
Source of above z
. 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
to
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
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: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE