HomeMy WebLinkAbout2026-00004936 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I00111101100
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X125715
u, 9 u21 3 9 1 u,99 U299 u,99 U2 1 U1 99 U2 99 1 11 u, 1 U211 �K P 0119�K
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 202612026-00004936 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f7
BOWES RD Elgin
® ❑ RELATED ®Y 0 N 01 25 2026 ®AM ❑YES ®NO U1
PRIVATE mo /day/yr 11:15 ❑PM FLOW CONDITION ITT
®15 0/MI ON E S W N Randall Rd COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR NISLOW 15
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
lE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N El UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1 6 lI,_ 1 O
I— 0 9 FIRST CONTACT 7 ;REA _5 COM VEH 0 Ea
99 *If Yes.See Sidebar U1
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
unk ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unk 1 I—
t HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr 9 Chevrolet Traverse 2023 00-NONE ,�_"j t2 -_, DUE TO CRASH ❑ 273
0 13-UNDER CARRIAGE to l 2 FIRE El El U2 C
II
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
POINT OF 8 I 4 COM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 7 -�I_5 •(ryes,See Sidebar C
PINGREE GROVEZ IL 60140 0 1 DZ30337 IL 2025 i 0 N
IL D 1 G N ERG KWOPJ 101184 Progressive ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 909797505 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)r(TELEPHONE) (EMS) (HOSPITAL)
2 6 01 /
' D
/ / 4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 9 O1 ,26 i2026 11 18 ®p PM AM 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 03
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ❑PM, ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM '
o N ® 11 4 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,_,Utility SLMT
45
r 2 0 ARREST NAME AM
7 1 r O PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 45
540-Dykema.Tracy - / / ❑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 -<
c ` -'- -' 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_ J I I I `4��I N _ } (example:shuttle or charter bus):or
L I I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O A
- . - . transporting employees in the course of their employment(example:employee73
transporter-usually a van type vehicle or passenger car):or 73
L L.___a__._: — — 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } } for direct compensation(example:large van used for specificpurpose):or [he driver,
I I I I Pe ( P 9 Pe or
VMS--IMG>_,
L ' l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
— ? - placarding(example:placards will be displayed on the vehicle). XI
-I
CARRIER NAME Z
t-I .imel I - ADDRESS '0
111i7 Not To Scale I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
.) xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ❑ No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No ❑ 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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE