HomeMy WebLinkAbout2026-00006478 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004127508
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202612026-00006478 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
RT20 EB Elgin 07:57
® ❑ RELATED ❑Y ®N 02 03 2026 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W GRACE EXIT RAMP COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl)❑ 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
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
1 1 /
yr
Kia Motors Co rnival 2024 00-NONE 1 i •-t DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 i 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 SY is-OTHER
4 ❑Y ONM❑UNK VEH. O AT CRASH IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 ji,4 COM VEH 0 LK 4 0
H 1- HARVARD IL 60033 0 1 0 FIRST CONTACT 1 7 : __5 *Ilves.See Sidebar u1
Z EX24655 IL 2026 REAR
TELEPHONE
IL D KNDNB4H38R6440645 Allstate El ®N U2 M
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 923436028 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 N4v 0 NCv 0 CIRCLE NUMBER(S) U1
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yr 12 _ C1
o 13-UNDER CARRIAGE 10 I 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR O
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 9 -
POINT OF s-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-6 COM•I sVEH See •Sidebar❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
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DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 1 2 I DOT I DOT curb sign 02,03 ,2026 07 57 ®❑pM 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 ❑ 39 6 2300 S DIRKSEN PKWY Springfield. 62764 28 28 , / pM
t
❑ , El Construction �F
R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
-a, ARREST NAME Tatsumi. Michelle.S. 11-601 1504000560 / / El PM SLMT
o N 1 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
t 2 0 ARREST NAME AM
7 ! r ❑❑PM ❑Unknown work zone type U1
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y
1504-Real, Hilario 401 03 ,24,2026 01 30 ®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.
' 0
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 -<
c ` -'- ' INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
/ _ } (example:shuttle or charter bus):or
/ / 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
/ y I. } } transportingemployees in the course of their employment/ pbymar):or ample:employee w
/ transporter-usually a van type vehicle or passenger car):or c0
4. Is used or designated to transport between 9 and 15 passengers,including N---- ----; / } } } g po pafic p rs,):or i the driver,
for direct compensation(example:large van used for specific purpose):or
L L____a....� e���r�" p // // l. I 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
O/ / placarding(example:placards will be displayed on the vehicle). XI
D
�,_,Lp '"" � ® / //^� _ CARRIER NAME Z
, / / ADDRESS 0
/ rn
/ CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I i Not To Scale) a ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
----- ----1 USDOT NO. ILCC NO. C
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE