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HomeMy WebLinkAbout2026-00007874 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III 11 IIII UH UU I IlU III III IlUl 1 U DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004134553 u, 9 U21 1 1 1 U199 U2 1 U,99 1_12 1 U,99 U2 1 1 10 u, 4 U2 11 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00007874 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1 15 CLOCK TOWER PLZ Elgin03:40 ® ❑ RELATED ❑Y ®N 02 10 2026 DAM ❑YES ®NO U1 _ PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 15 0 ❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT RUN 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 0 / / FOR DAMAGEDAREA(S) FROPtf TOWED U1 0 Unknown,O. Unknown Unknown 00-NONE „ 12 , DUE TO CRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN = $ 4 COM VEH 0 ZgJ r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[S !i,_ 1 00 ~ 0 9 9 FIRST CONTACT 99 7_; _5 *UYes.See&debar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/ Unknown ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 99 0 m �{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 NMV 0 NCv 0 DV 0 0 0 FROM TOWED XV Crosstrek 2.0 2017 00-NONE Q"i 2 p DUE TO CRASH ❑ 2 0 13-UNDERCARRIAGE 10i ©l( 2 FIRE 0 ® U2 C c F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 0 Y Ni N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracl n Value U1 9 POINT OF 8 i1� "4 COM VEH ❑ ® W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 1 Y _,-_5 •• •If Yes.See Sidebar — Huntley IL 60142 0 1 0 FY18678 IL 2026 I:EaR 0 C IL D 0 JF2GPAKC9H8219898 State Farm ❑Y ®N RDEF P3 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Same 3615954SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 9 02/10 l2026 03 43 ®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 C) 2 ❑ 30 99 N 3 0 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 -a, ARREST NAME / / ID PM ' o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 99 ARREST NAME AM Ti 2 ❑ ❑❑PM 0 Unknown work zone type U1 / 1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 99 1 51 2-Juarez-Huichapan.Juan 400 / / ❑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 -< c ` --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 - ------I----; Unit transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employee transporter Fkillrtit'daA" Orrt�rot } F t ansporter-usually a van type vehicle or passenger car):or L -----}----; / ' - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N 0, for direct compensation(example:large van used for specific purpose):or I. L i.____a____. � i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT) m 1 placarding(example:placards will be displayed on the vehicle). > CARRIER NAME Z ADDRESS 0 D Not To Scale I 15/GIpe1i T n CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I r ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above 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 to 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 Tan u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE