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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X604176677-
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00013570 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
2486 BUSHWOOD DR Elgin01:13
® ❑ RELATED 0 Y ®N 03 11 2026 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ FT!MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
&RUN
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED CI PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Sohal. Harpartap.S. 1 2 /
yr 13-UNDER CARRIAGE 1 IE
0. !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 0 m
M 1 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI all 4 COM VEH ❑ El 1 C)
~ ELGIN IL 60124 0 1 0 FIRST CONTACT 7 O7 .:LQ_-5 *II Yes.See Sidebar U1 0
Z ET13941 IL 2026 REAR
TELEPHONE
IL D 0 4JGFB4FE8RB253028 Geico El igiJ N U2 M
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6142550943 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 NOV 0 DV CIRCLE NUMBER(S) U1
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o 13-UNDER CARRIAGE 10( I. FIRE ❑ ® U2 C
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SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16
❑ NJ -TOP 3 0 X
a Y N D UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 -4ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 '+�.5 COM•IesVSee Sidebar ® W
H 4301134B IL 2026 REAR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 C6RR7TTOHS540144 State Farm 0 V ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
Hall.Steven.W. 3587288SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
Ui =
{UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (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 ® 18 5 03,11 l2026 01 32 ®❑PM AM in a Work Zone? ®N DIRP D
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1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 ❑ 30 99 , , ❑PM ❑Construction *
Z 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Sohal. Harpartap.S. 11-402-A 1557000217 / ! El PM SLMT
oN1 El11 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0• Utility
r 2 ElARREST NAME AM
00
7 ❑❑PM ❑Unknown work zone type U1
1 r
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 00
1557-Wieske. Nathan 901 331-Ziegler 04 ,06,2026 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 VO INLVED,USE SR 1050A
r �....,,....., , ® ; A CMV is defined as any motor vehicleused to pounds(example:transport passengers or property and:or Z
Not.fi b l 1. Has a weight rating more than 10,000 dle:truck truck trailer
r r -'- -' { r INDICATE NORTH combination):or
\ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - r r r (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- <.___A-.--J. O - y } } . transportingemployees in the course of their employment
�„'Iimmi r trasportr-usuall a van type vehicle or passen car (orxample:employeew
L -----}----+ I - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or O
L i t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
—I
CARRIER NAME Z
ADDRESS 0
Moulds" VD/)
Bar i. i. i. i. 4. C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"---- --1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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
0
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
Burgundy Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE