HomeMy WebLinkAbout2026-00008688 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 0
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ❑ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00008688 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
BLUFF CITY BLVD El In 06:15
® ❑ RELATED ' ' 0 N 02 14 2026 ®AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W G I FFORD RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 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 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGED AREA(S) FRO4T�TOWED U1 0
De Pauw. Richard. E. 1 0 /
yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 NIC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 6 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i1 6 1i,4 COM VEH El El1 O
m H ELGIN IL 60120 0 1 0 FIRST CONTACT 1 7 ; __5 *IrYes.SeeSidebar U1
Z CF14533 IL 2026 E
TELEPHONE
IL D 0 KM8J3CA42LU148349 State Farm ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2006666-SFP-13 1 1-
15 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 INV 0 NOV 0 DV
yr 12 _ C
o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 9 -
POINT OF s-.. -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=5 COM•I sYEH See •Sidebar❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 3 Bluff City Cemetary Fence 02,14 ,2026 10 08 ®❑pM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 50
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
;, 2 D 34 3 945 BLUFF CITY BLVD ELGIN IL 60120 06 99
t ! ! ❑PM, ❑Construction *
N 3 ❑ 43 3 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
—a, ARREST NAME / / El PM '
o N 1 ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
t 2 ARREST NAME AM
! r ❑❑pM ❑Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ - ID Am Workers present? ❑
566 Lopez• Eric 401 ! , ❑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 -' 0 r INDICATE NORTH combination):or .Z-1
} h` � }BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } r r ,. (example:shuttle or charter bus):or
3. Is designed to car 15 or fewer passengers and operated a contract carrier OC)
} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L i..__4._ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
I % Pe ( P 9 Pe or O
a
r ( l. l. I 1 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
I
1 CARRIER NAME Z
�� I ADDRESS l
I CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scale I ( 0 Not in Comm./Govt. 0 Not in Comm./Other 0
‘I. - --1 - USDOT NO. ILCC NO. m
m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Brown
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_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE