HomeMy WebLinkAbout2026-00006951 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Dt 2 Sheets 01111101111 10011110 1111 III 1111 III 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004130704
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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 El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
0 AMENDED YR 202612026-00006951 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
S MCLEAN BLVD El In09:06
® ❑ RELATED ®Y 0 N 02 05 2026 ®AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W RT20 EB COUNTY PROPERTY ❑Y El N DOORING ❑y #OF MOTOR 0 SLOW 6 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n
FOR DAMAGEDAREA(S) FROM TOWED U1 0Avina.Jessie.G. 0 7 /
yr 13-UNDER CARRIAGE 10. 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 rn
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 916•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, it 6 4 COM VEH 0 ZgJ 1 0
H F.
EAST DUNDEE IL 60118 2413 0 1 0 FIRST CONTACT 12 7 : __5 *Ir Yes.See Sidebar U1
Z205939C IL 2026 E
TELEPHONE
IL D 1 FTYR1 ZM 1 H KA08693 American Family Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same CA00040596 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 KCV ❑Dv
!1 9 9 8 International C 1 Mfg 2025 00-NONE ,;_i t2--_, DUETO CRASH ❑ ® 14 x
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6
FIRST CONTACT 5 7I- 4 COM VEH El 0 U1 CO
•If Yes.See Sidebar C
Racine WI 53403 0 1 0 G D97050 WI 2026 PEAR 0 Si)
WI D 7 1 HTEU M M L1 SS287283 Continental Casualty Comp ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
1 99 9 Revere Electric Supp 7033800103 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 02,05 l2026 09 30 ®❑AM
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 �
0 2 0 03 15 { ) 0 PM 0 Construction *
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 4 ARREST NAME Avina.Jessie.G. 11-601 435000739 / / El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM U1 35
t 2 ❑ ARREST NAME 02)05 12026 09 35 [M PM 0 Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? 0 Y 35
435-Mahan. David 701 397-Jones 03 ,02,2026 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.
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 -<
` ` --I -' r INDICATE NORTH combination):or -I
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 -----I-----; Ell - I. } } transporting employeesned to inthe course or fewer passengers
heemplooynd ment example:employeerier X
transporter-usually a van Type vehicle or passenger car):or C
L L.___a____� I I- } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
ip for direct compensation(example:large van used for specific purpose):or O
/ wrmaoar 1 -D
' / / "" - l. I } 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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I placarding(example:placards will be displayed on the vehicle). :0
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Iv �� . CARRIER NAME Revere Electric Supply CO Z
0
._ ADDRESS 821 S AIRLINE RD
w
CITY/STATE/ZIP Racine I WI 153406 M
0
MOTOR CARR.ID El Interstate El Intrastate
0
I r Not in Comm./Govt. 0 Not in Comm./Other
%---------1 - % % % % uSDOT No. 2427320 ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes ® 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 ®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
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE