HomeMy WebLinkAbout2026-00007492 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 10011110 1111 III 1110 1 I 0
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00007492 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
3 CLOCK TOWER PLZ Elgin04:00
® ❑ RELATED ❑Y ®N 02 08 2026 DAM ❑YES ®NO U1
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl)
❑ FT l MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ICU 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 4 /
yr 13-UNDER CARRIAGE ) 2 ' 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 2 SY4 ❑Y ®SNE El LINK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI B 4 COM VEH ❑ j$J 1 00
~ Hanover Park IL 60133 0 1 0 FIRST CONTACT 12 7 ;1 _5 *If Yes.See Sidebar U1
Z FL46143 IL 2026
TELEPHONE
IL D JN8AF5MR9DT207147 Magnum Insurance ❑Y JN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LAA-1093188-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv CIRCLE NUMBER(S) U1
!1 9 of 2 Honda Odyssey 2013 00-NONE N_' 12 "_, DUE TO CRASH ❑ ® 98
0 13-UNDER CARRIAGE I 2 FIRE 0 El U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 0916•TOR 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si B i.',_4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 9 7 _, _5 •IfYes.See Sidebar C
E LG I N Z I L 60123 0 1 0 Q711456 I L 2026 REAR Si)0
M
IL D SFNRL5H69DB045840 State Farm ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Hall. Robert.T. 2883449-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 02 r 08 /2026 04 27 ®PM in a Work Zone? NJ DIRP co
I I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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2 ❑ 2 99 r r 0 PM ❑Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME r / ID PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
r 2 ❑ ARREST NAMEAM
c- T r / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 10
562-Hernaindez. Myra 320-Cox 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 INLVED,USE SR 1050A
ADDITIONAL UNITVOS FORMS.
r ----r••--, , A CMV is defined as any motor vehicle used to transport passengers or property and:
01. Has a weigh Z
Not TO Scale t rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' T r 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
X
I- L.__-a-.--i i-, } } } } transportinggemploo aeeslIn the course 5 or fewer passengers
their employment
ment operated bmpy a contract:employee carrier O
I ' ''.1- ) transportr-usually a van type vehicle or passenger car):(orxample:employee w
i. L____a rill I. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver,
Pe ( P 9 Pe p pose):or O
L i t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). ,Zmt
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CARRIER NAME Z
ADDRESS 0
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97CIockTTower7Plz CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
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I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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Xl
IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE