HomeMy WebLinkAbout2026-00015780 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004175861
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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 El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202612026-00015780 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ®Y 0 N 03 22 2026 ®AM ❑YES ®NO U1
LARKIN AVE Elgin11:12
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W MONROE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. ❑EWES ❑NW ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
0 9 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
F 2 SY5 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 15-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�a �i 4 COM VEH ❑ j$J 2 O
~ ELGIN I L 60123 B 1 0 FIRST CONTACT 1 7 ; __5 *Il ves.See Sidebar U1
ZEY28108 IL 2025 REAR
TELEPHONE
IL D 0 1 C3CDZAB2EN 195569 State Farm ❑Y N N U2 53 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 0866134-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Provena St.Joseph ❑Y El 2 0
m N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NOV 0 DV CIRCLE NUMBER(S) U1
2 O O 6 Honda Civic 2020 00-NONE 0. Q!•-O DUE TO CRASH rg ❑ 2
0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 5 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y IDN ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH 0 N U1 CO
FIRST CONTACT 12 7A .5 •If Yes.See Sidebar
H ELGIN IL 60120 B 1 0 EQ75974 IL 2026 I 0 C
M
IL D 0 2HGFC2F67LH537295 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 3757515-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPOND❑N 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 1 03,22 ,2026 11 30 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 0 2 15 03,22 ,2026 11 13 ❑PM 0 Construction *
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ®AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Ponce.Coda. L. 11-901.01 435000741 03/22,2026 11 16 ❑PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
0 AM
t 2 0 ARREST NAME 03 r 22 ,2026 12 15 ®PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
435-Mahan. David 601 367-Stein 05 ,04,2026 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 -<
` ` -'- ' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} i., - ` - i. e. r t- (example:shuttle or charter bus):or 0
1 Not To St� J _ 0 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
-_ -- } } } transporting employees v In the course of employment caant(example:employee COtransporter-usually a van type vehicle or passenger car):or �
C
} } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. to
for direct compensation(example:large van used for specific purpose):or O
L L____a____.I unt2 j _ t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
— — o placarding(example:placards will be displayed on the vehicle). XI
uti
r r -1- '.. i 1 u.rrxw t
CARRIER NAME Z
ADDRESS
w
o
I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ 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
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
White Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE