HomeMy WebLinkAbout2026-00012075 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1001111010 III fl
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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 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00012075 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
ELIZABETH ST Elgin01:40
® ❑ RELATED ®Y 0 N 03 03 2026 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT N E S W DIXON AVE COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 5 !
yr ++- +2 -
13-UNDER CARRIAGE + DUE TO CRASH ® ❑
101 • 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 ❑Y ®SNE❑ 15-OTHER
UNK VEH. O ATCRASHD O 99-UNKNOWN +6-TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� �'.4 COM VEH 0 Ea 1 C)
H F. Elgin IL 61020 0 1 0 FG52141 IL 2026 FIRST CONTACT 8 Qi _: __s *Ir Yea.See Sidebar Ut
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TELEPHONE
IL D 0 1 HGCM56794A056667 Kemper ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12AU001467481 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑r uv 0 NOV ❑DV
!1 9 9 8 Dodge Ram ProMaster 2020' 00-NONE .1.,-1 Q1.,-_+ DUE TO CRASH (g► 21 C
0y Yr 13-UNDER CARRIAGE 19( I 0 FIRE El U2 C
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M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraglon Value 0
POINT OF 8 i1 A -4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� Bs •(ryes,See Sidebar
— Kirkland IL 60146 0 1 0 3017545B IL 2026 I 0
Z M
IL D 0 3C6TRVAG2LE141621 West Bend ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Enterprise FM Trust A99864403 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (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 ❑Y U2 Z
N 1 ® 11 4 31 ,12 !26 01 40 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 23 99
N + 3 0 CITATIONS ISSUED 0 PENDING + ! ❑PM- ❑Construction >E
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
—a, ARREST NAME / / ❑PM '
o N 1 ® 11 4 ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
r 2 0 ARREST NAME AM
7 1 r O PM 0 Unknown work zone type U+
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
482-Flentye,Jeremy 401 41 , 12 ,26 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
6 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} -----------' Eld"dem7st �1 - } INDICATE NORTH combinatbn).or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
A •— 3. Is tlesgnetl to carry 15 or fewer passen ers and o rated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
unit I transporter-usually a van type vehicle or passenger car):or w
L i.-----}----; 1300114wvaII In - I.
} } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, y
for direct compensation(example:large van used for specific purpose):or O
L L____a____. • _ l. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
—I
1 t r :- :- :-- --:-
CARRIER NAME Z
ADDRESS T.
'.Z
unit z 0
Not To Scale d CITY/STATE/ZIP
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./GaA. Not in Comm./Other
; _Y____1 - USDOT NO. ILCC NO. rn
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?
❑ Yes II No ElUnknown A
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
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE