HomeMy WebLinkAbout2026-00009172 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IM UH UU I IlU
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00009172 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
SHASTA DAISY CT Elgin 05:56
® ❑ RELATED ®Y 0 N 02 16 2026 12,— ❑YES El NO U1 —<
g PRIVATE mo !day!yr ®PM FLOW CONDITION IT1
FT N E S W RED BARN LN COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROf4r TOWED U1 0
Thakkar.Janki. D. 0 1 /
yr 13-UNDER CARRIAGE 10 12 �. 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 r11
F 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASIN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL B 4 COM VEH 0 Ea 1 00
~ ELGIN IL 60124 0 1 0 FIRST CONTACT 12 7_; _5 *IIYes.See Sidebar Ut
Z 385863 IL 2026 E
TELEPHONE
IL D 0 JTEDW21A460003121 AAA ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same AUT700908384 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
0 DRIVER 0 PARKED 0 DRIVERLESS DA FED 0 PEDAL 0 EWES 0 r My
yr 12 ,_ X
o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
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M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 9 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value
POINT OF 8 i1� 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 14 711- --s •• •IryeS,See Sidebar C
= ELGIN IL 60124 B 1 0
9 Sn
IL ❑y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 6 x
Elgin Fire 1 51 2 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER Y NJ U1 =
(UNIT) (SEAT) (DOB! (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 12 1 02/16 /2026 06 22 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
v 2 2 23 02,16 /2026 05 57 mi PM ❑Construction *
R O 0 ]$I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ❑AM 0 Maintenance U2
—a, ARREST NAME Thakkar.Janki. D. 11-1204-B s1519-489 02/16/2026 06 01 ®PM SLMT
1 ® 12 1 0 CITATIONS ISSUED ❑PENDING Utility
o uSECTION CITATION NO. ROAD CLEARANCE TIME El
T 2 El ARREST NAME 02/16 /2026 06 11 ®PM ❑Unknown work zone type U1 05 AM
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1519-Bae2 a.Guadalupe 801 269-Mendiola 04 ,07,2026 09 00 ❑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- }---.r----; - I. combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
Not To Scale) 3. Is designed to carry15 or fewer 0
` -- g passengers and operated by a contract carrier I O
�— I. } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; - - } } } 4. Is used or designated to transport between 9 and 1 passen rs,including the driver,
C
_uar 1 for direct compensation(example:large van used fors specific purpose):or O
' —it, 1 l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
I placarding(example:placards will be displayed on the vehicle). m
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CARRIER NAME —I
ADDRESS
T.
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CITY/STATE/ nZIP 0
I - MOTOR CARR.ID 0 Interstate El Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"---- --: - USDOT NO. ILCC NO. rn
73
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. P3
XI
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 E
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 0 0 Z
1-1
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE