HomeMy WebLinkAbout2026-00018186 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
III II IIIIII UH
II II IIII III II IIIIIIIIIIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004197016
u, 1 U21 2 4 1 u, 2 U2 1 u, 9 U2 1 u, 1 U2 1 1 10 u, 3 U2 1 *P 0119
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 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
0 AMENDED YR 202612026-00018186 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN CLIFTON AVE Elgin 02:27
® ❑ RELATED ®Y 0 N 04 03 2026 ❑AM ❑YES ®NO U1 -<
_ _ PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES ❑uuv 0!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
0 5 !
Acura MDX 2009 00-NONE „ Oi-, DUE TOCRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<r1
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 76•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,.4 COM VEH 0 g! 1
H 1 ELGIN IL 60123 0 1 0 Q323474 IL FIRST CONTACT 12 Y ; _s Yes.See Sidebar Ut 0
ZREAR
TELEPHONE
IL D 2HNYD284X9H522664 PROGRESSIVE ❑Y ❑N U2 I''I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 944773849 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES ❑iiuv 0 NCv ❑Dv
yr!1 9 9 5 Hyundai Kona 2021 Do-NONE O,' t2 "_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7�_, _s •If Yes.See Sidebar
H ELGIN IL 60123 0 1 0 DY47695 IL 2025 RFJ
M
IL D KM8K12AAXMU712468 GEICO ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 6045068225 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / M 2 3 0 1 0
m
/ / #OCCS D
71
/ / u1 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 41 ,12 /26 02 27 ®PM AM in a Work Zone? ®N DIRP D
co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 06 99 41 /12 /26 02 28 ®pm ❑Const action >E
0 4
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Huber.Jessica. L. 11-902 S1568-000033 41 !12 !26 02 32 ®pM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
t 2 El ARREST NAME 41 /12 /26 02 40 0 PM 0 Unknown work zone type U1 0 AM
3O
x T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1568-Bae2.Amkar 600 / ! ❑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 -<
} ;----; I N combination):or —I
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
I I 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 w
L L.___a__ � 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
I I Pe ( 9 Pe or
_a _ Unit2 � " ' - i. . i. ,_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
•
__ • piacarding(example:placards will be displayed on the vehicle).
fi XI
r. D
,
1 I CARRIER NAME Z
ADDRESS 0
D
CITY/STATE/ZIP g
Not TO Scare , I MOTOR CARR.ID ❑ Interstate ❑ Intrastate
i ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
‘I. - --1 USDOT NO. ILCC NO. C
m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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
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
Black White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
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