HomeMy WebLinkAbout2026-00005330 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10011110110011DIN00
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 125,16
u, 9 u210 1 1 1 U,99 U2 1 U199 1_12 1 u,99 U2 1 4 9 u, 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00005330 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 'n
826 DUNCAN AVE El06:24
® ❑ RELATED ❑Y ®N 01 28 2026 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W &RUN
Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
ID AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER I] PARKED D DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE !„ 12 , OUETOCRASH ❑ VI
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) U2 2 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 DISTRACTED 0 0 _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Vatuc 9 ALGN
6 4 COM VEH ❑ j$J
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1[6 !i,_ 1 00
I— 0 9 0 FIRST CONTACT 99 7_; _5 *IIYes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
N/A ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same N/A 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER 0
5, ❑ DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 Dv
yr 13-UNDER CARRIAGE
O
o I � 2 FIRE ❑ El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9
a CI Y ❑N CI UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value
POINT OF 8 -4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -j�'`_ COM VEH ❑ ® CO
FIRST CONTACT 11 7 _, _6 ••(ryes.See Sidebar
H CR90608 I L 2026 REAR 9 cn
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 5N1AT2MV3HC780725 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0260097-SFP-1 3 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPONDER❑Y u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 01 ,28 l2026 06 24 ®❑pmn 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
2 ❑ 99 18
N 3 ❑ CITATIONS ISSUED 0 PENDING + , ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME ! / El PM '
o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
00
r 2ARREST NAME AM
T 1 r ❑❑PM CI Unknown work zone type U1
Eln OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
471-Evans, Lakysha 102 - r ! ❑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 -
Slade?Ave. INDICATE NORTH combination):or —I
p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
L ...I.
I transporter
designated totransportbetween9a dr15passengers,includingthedriver. to
} for direct compenation(example:large van used for speific purose):or O
I < i. i. _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires D
placarding(example:placards will be displayed on the vehicle). XI
. 41.1
w►a I CARRIER NAME Z
N I ADDRESS D
w
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
. ; ❑ Not in Comm./Govt. ❑ Not in Comm./Other
Not To Scale j O
i' --- --4 USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE