HomeMy WebLinkAbout2026-00009097 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
10011110111fl H11101111000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004141/49
u, 1 U21 3 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
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/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00009097 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15
® ❑ RELATED ❑Y ®N 02 16 2026 ❑AM ❑YES ®NO U1
S RANDALL RD Elgin12:49
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
FT!MI N E S W SOUTH ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
lgi 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 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Berg. Mary.A. 1 2 /
yr 13-UNDER CARRIAGE 10 !. 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i� 6 �r.4 COM VEH 0 Ea 1 n
V. I . Elgin IL 60123 0 1 0 Z643943 IL 2027 FIRST CONTACT 5 7 : _O = Yes.See Sidebar Ut
REAR
TELEPHONE
IL D 1C4NJRBB9FD279696 Country ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Berg. Phillip P12A8218978 1
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r
RESPONDER D
Refused ❑Y El 2 eu
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0 o v 0 KV 0 Dv
!1 9 4 6 Ford Exy yrplorer 2018 00-NONE i1_"j Q�,-_, DUE TO CRASH ❑ (� 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
M 2 4 ❑Y El ❑
SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
NDUNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7�_, _6 •If Yes.See Sidebar
H ELGIN IL 60123 0 1 0 FJZ-DV IL 2026 I O C
IL C 1 FM5K8D89JGC03827 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire Same 0711270SFP13 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEXI {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ / 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 City of Elgin Traffic sign contol box 02,16 /2026 12 50 0 pm 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
Eri 2 0 150 DEXTER CT ELGIN IL 60120 2 25 02,16 ,2026 12 51 PM
® - ❑Construction >E
R O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 U2
ARREST NAME Berg. Mary.A. 11-902 298001364 02,16/2026 12 56 ®PM M ❑Maintenance SLMT
o u ® , ElUtilit 11 4 CITATIONS ISSUED PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME •
AM y
t 2 0 43 5 ARREST NAME 02/16 /2026 01 37 ®PM 0 Unknown work zone type U1 50
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50
298-Lopez, Mirko 800 03 , 10/2026 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` -' -' r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
C)
M j H
3. Is desgned to car 15 or fewer passengers and o rated a contract carrier O
- y } } } transport) em to ees In thecoursee of their emp
loyment(example:employee
_ transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including w}--- ----; as ,, - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
, , • , Ransom.
L____a....1 s�' — — — — -N� - i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m
r i placardig(example:placards will be isplayed on the vehicle). ;p
um� j Nor To Scale >
- --
— — — — CARRIER NAME Z
_ __ ADDRESS 'n i
1I1I1 ' D
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
0
I r ❑ Not in Comm./Gout. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE