HomeMy WebLinkAbout2026-00008252 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00008252 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 02 12 2026 ®AM ❑YES ®NO U1 -<
SHALES PKWY Elgin07:28
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W SUMMIT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGEDAREA(S) FIX)Ni TOWED U1 0Fer Keosha.S. 1 1 /
yr 13-UNDER CARRIAGE �a:) 2 , 2 FIRE 0
IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 3 <<T1
F 2 SY4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S i�S 4 COM VEH ❑ j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1
Z DR76291 IL 2024 REAR
TELEPHONE
IL D WA1 LAAF75H D017055 State Farm ❑Y ign4 U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3843912SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 c
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑MAv 0 iv ❑ CIRCLE NUMBER(S) U1
DV
/1 9 yf 1 Subaru Ascent 2022 Do-NONE ,t"i 12..-_, DUE TO CRASH ❑ [gI 2
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI S l'_4 COM VEH D ® U1 CO
FIRST CONTACT 6 Y :j_ ,-5 •If Yes,See Sidebar
H ELGIN Z IL 60123 0 1 0 DR12126 IL 2026 FIRST
M
IL D 4S4WMAKD7N3445194 All American ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same Al CJ095180 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
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 r 12 l2026 07 28 ®❑PM AM in a Work Zone? ®N DIRP D
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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 �
0 2 ❑ 28 03 { / ❑PM ❑Construction *
Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o 1El 11 4 ARREST NAME Ferguson. Keosha.S. 11-601 1504000563 r ! El PM SLMT
ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N 0 AM25
r 2 El ARREST NAME Ferguson. Keosha.S. 3-413-F 1504000564 r r PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 25
1504-Real, Hilario 202 03 r 24 r2026 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 -<
` ` -'- ' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
® (example:shuttle or charter bus):or
X
I- <-----I----; I I ` - transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employeener X
a„... transporter-usually a van type vehicle or passenger car):or CO
L 4. Is used or designated to transport between 9 and 15 passengers,including C
}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
t 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). m
—I
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CARRIER NAME I
ADDRESS O
$ D
rn
_Not To Scale I - CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE