HomeMy WebLinkAbout2026-00018663 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 III 11 II III1II MIMI U l IlU Ifl iiflhl 1011111 UU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XOO4197021
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00018663 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED PRIVATE ❑Y ®N 04 06 2026 ®AM ❑YES ®NO U1 -<
BIG TIMBER RD Elgin mo /day/yr 05:54 ❑PM FLOW CONDITION m
020 ®!MI N OE S W Hillcrest Rd COUNTY PROPERTY ❑Y ® N DOORING ❑V #OF MOTOR 0 SLOW Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
2017
FOR DAMAGEDAREA(S) FROf4r TOWED U1 Q
0 1
yr
13-UNDER CARRIAGE VI E
10 1 2 FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COIN VEH ❑ El 2 O
Lake In The Hills IL 60156 0 1 0 FIRST CONTACT 11 7_: __5 *Ilves.See Sidebar U1
Z CM86144 IL 2026 REAR
TELEPHONE
IL D 1 C4RJ EAGZHC716289 State Farm ❑Y ®N U2 m
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2763516SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 INv 0 Ncv 0 DV CIRCLE NUMBER(S) U1
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o 13-UNDER CARRIAGE 10.i t, 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 -
POINT OF s-.;, 4
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 15 1 Department of Natural Resources Deer 41 ,12 ,26 05 54 ®❑pM AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 70
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1
;, t 2 ❑ 1 NATURAL RESOURCES WA5'pringfieldL 62702 21 99 , , ❑AM ❑Construction *
ZJ 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME ! / ❑PM
ou ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
r 2 El ARREST NAME AM
T ! ! PM CI Unknown work zone type 45
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ - ❑AM Workers present? ❑
298 Lopez, Mirko 501 , , ❑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
i- }-- --I-- --' I
I
} INDICATE NORTH 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
combination):or -<
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
y _ (example:shuttle or charter bus):or
A ( ` � ,
r 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 c0
L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
HamR7RU.
i L I L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
L L a placarding(example:placards will be displayed on the vehicle).
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XI
CARRIER NAME —I
- ADDRESS
I =N�
>- ( CITY/STATE/ZIP g
Not To Scalei.I - MOTOR CARR.ID 0 Interstate 0 Intrastate
I I l I I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
----- """'1 USDOT NO. ILCC NO. C
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XI
Source of above z
. ❑ 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Maroon
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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE