HomeMy WebLinkAbout2026-00009426 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00009426 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ®Y 0 N 02 17 2026 ❑AM ❑YES ®NO U1 -<
S LIBERTY ST Elgin10:12
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W MAY ST COUNTY PROPERTY ❑Y 1�1 N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 wcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROftf TOWED U1
NAME(LAST,FIRST,M) mo
/1 9 9 5 Honda Accord 2021 00-NONE
13-UNDER CARRIAGE 11 . 12 DUE TOCRASH ® 0! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ,U O DISTRACTED ® 0 U2 O m
M 2 8 ❑Y ®$NE❑LINK VEH. O AT CRASH IN ENGAGEO 99-UUNKNOWN 9 16-TOP) ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6• iI 6 it®COM VEH 0 0 2 C)
FFIRST CONTACT 3 7 _,--_;_OS •Ir Yes.See Sidebar Ut 0
Z Chicago IL 60610 B 1 0 FR92805 IL 2026 REAR
7 TELEPHONE
IL D 0 1 HGCV1 F33MA024123 Integon Casualty ❑Y Igl N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same 2030341975 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ElN 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 rouv 0 NO/ 0 Dv
� !1 9 yf 0 Jeep(after 19681�rokee 2016 00-NONE O, Qj'O DUE TO CRASH ❑ 2
...
13-UNDER CARRIAGE FIRE ❑ ® U2 C
F 2 8
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3
❑Y ON ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-il�;-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y j -5 •If Yes.See SidebarC
F. ELGIN IL 60123 B 1 0 FN76442 IL 2026 I 4 ((I)
M
IL D 1 C4PJMCB1 GW330933 American Alliance ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Elgin Fire Same I LAA-1120478-00 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 21 /71 /026 10 12 ®AM in a Work Zone? ®N DIRP D
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 C)
Fic 2 0 23 28 21 ,71 /026 10 19 ®PM ❑Construction
E
R 3 0igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
-a, ARREST NAME (CART. KEWINS.A. 11-1204-B 1525000953 21 /71 /026 10 23 ®PM SLMT
o u 1 ® 11 4 •CITATIONS ISSUED 0 PENDING Unlit
o Nlgi SECTION •CITATION NO. ROAD CLEARANCE TIME AM, Ely
t 2 ElARREST NAME (CART. KEWI NS.A. 11-601-Ax 1525000954 21 1 71 1026 1 1 00 0 PM ❑Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1525-NavE.Oscar 401 320-Cox 31 , 41 /026 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.
I 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
40
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
CO I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} } ; I Not To Scale 1 combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
(example:shuttle or charter bus):or n
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
------.;
} } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
`.___A Unit i - 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
. ;O1 `� } } for direct compensation(example:large van used for specific purpose):or O
L L--_-a-___. k I - t } } } L 5. Is an vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be isplayed on the vehicle). XI
-I
—it - CARRIER NAME Z
Mey79t _ ADDRESS D
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. Not in Comm./Other
0 0
�"--------- - USDOT NO. ILCC NO. rn
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
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
Blue Silver
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE