HomeMy WebLinkAbout2026-00014092 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 100111101111 1011 1110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004182104
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00014092 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN MCLEAN BLVD Elgin12:53
® ❑ RELATED ❑Y ®N 03 13 2026 12,— ❑YES IX]NO U1
PRIVATE mo /day/yr ®PM FLOW CONDITION m
E05 ®0 !MI N E S VY West Highland Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
0 g Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZ1 N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FR
Jordan. Matthew.C. Ford Escape 2017 00-NONE
13-UNDER CARRIAGE ® m4r TOWED U1 Q
NAME(LAST,FIRST,M) mo yr 12 , DUE TOCRASH ❑
10 EN E
.I !�. 2 FIRE 0 lE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it 6 ii,4 COM VEH 0 j$J 1 0
Hanover Park IL 60133 0 1 0 FIRST CONTACT 11 7_:( __5 *IrYes.SeeSidebar U1
ZEP45297 IL 2026 REAR
TELEPHONE
IL D 0 1 FMCUOJDOHUF07581 First Chicago ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 BILLINGSLEA.Sammantha. N. ILV128331100 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES ❑ W 0 K V ❑Dv
!1 9 9 6 Buick Apollo 2008 00-NONE 11_"j t2"';-...m.,';-...m., DUETO CRASH ❑ t81 2 x
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN 0istraetlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1( 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 3 Y , _5 •IfYes.See Sidebar
H ELGIN I L 60120 0 1 0 AR41067 I L 2026 REARC
0 M
IL D 0 5GAER23778J198521 Bristol West ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Herrera. Maria G017479542 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
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1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ❑ 49 1 31 ,31 ,026 12 53 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
7 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ® 11 1 20 18
! 1 ❑PM• ❑Construction *
Z 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Jordan. Matthew.C. 11-708 1569000014 / ! El PM SLMT
l$l CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility
t 2 0 ARREST NAME Jordan. Matthew.C. 11-402-A 1569000014 31 1 31 1026 01 30 0 PM El Unknown work zone type U1 35
2 2 3 El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
449-Harris,Jacob 601 237-Copland 41 , 12 ,26 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 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 truckrtrailer -<
Not To Scale combination):or INDICATE NORTH p0
A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1 I p - } (example:shuttle or charter bus):or C
A }15 I IUV 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } } transporting employees in the course of their employment(example:employee X
,\'r f transporter-usually a van type vehicle or passenger car):o co
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1�, L+ 4. Is used ordesi natedtotrans rtbetween9and15 passengers, ng rCjt
r I. • } } •
for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
J 191 I t i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
< `----�`----i unrs - M
placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
ADDRESS 0
w
1 I I//
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----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? 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
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
Black White
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE