HomeMy WebLinkAbout2026-00006516 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II I 111 IIII
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00006516 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ' V 0 N 02 03 2026 ®AM ❑YES ®NO U1 —<
S MCLEAN BLVD Elgin 09:55
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FTlMI N E S W CRISPIN DR COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 2 fA
❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
! ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Unknown,O. Unknown Unknown 00-NONE „ 12 , OUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
f0l !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 4 <
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16.TOP 3 0 _
❑Y ®N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
$ 4 COM VEH 0 Ea
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -i�S �i2 O
I— 0 1 0 FIRST CONTACT 12 7_i REAR _5 *IIYes.SeeSidebar Ut
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2
NIA ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same NIA 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99 G0)
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�{ DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑i uv 0 NOV ❑DV
!1 9 y 2 Chevrolet Silverado 2023 00-NONE 10 1 t2 c,�2 FIRE DUE ID
CRASH 0 ® U2 2 73
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9
POINT OF S i —4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
FIRST CONTACT 6 O7 ,�_QIOS •If Yes,See Sidebar C
Shabbona IL 60550 0 1 0 4038805B IL 2026aR 0 fp
Z D
IL B 0 1 GCPTCEKOP1209180 West Bend ❑Y ®N RDEF ZI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Midwest Ground Cover A818250 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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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 1 02,03 /2026 10 31 ®❑PM 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 0 03 28
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a, ARREST NAME / / 0 PM
o N El 1 0 •
CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
35
f 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
471-Evans, Lakysha 701 - r / 0 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
i- }-- _r_ --; ® 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
combination):or -<
- _ —IINDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. _ } (example:shuttle or charter bus):or
0
L A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee X
. transporter-usually a van type vehicle or passenger car):o co
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i_ i. ----; - I. } } } •4. Is used or designated to transport between 9 and 15 passenge including the driver. N
for direct compensation(example:large van used fors specific purpose):or
L L____a____. _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
z placarding(example:placards will be displayed on the vehicle). ;p
. 1
CARRIER NAME Z
ADDRESS 0
V)
i i i i ....i r
CITY/STATE/ZIP 00
_ O
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scale 1
I I T I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i. -----1 - % % % USDOT NO. ILCC NO. rn
XI
Source of above Z
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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
Tan Green
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE