HomeMy WebLinkAbout2026-00019897 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00019897 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
KI M BALL ST El In03:01
® ❑ RELATED ❑Y ®N 04 11 2026 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W N GROVE AVE COUNTY PROPERTY ❑Y ® N DOORING ICIY #OF MOTOR 0 SLOW 15 co
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 5 !
yr 13-UNDER CARRIAGE 1a i : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 2 m
F 2 4 ❑Y ®SNEM❑ 15-OTHER
UNK VEH. 0 AT CRASHIND 0 99-UNKNOWN 9 76•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il S 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7_; _5 *Yves.See Sidebar U1
Z UNKNOWN IL ' E
TELEPHONE
IL D KN DJ P3A55G7261492 Bristol West Insurance ❑v Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same G01588184102 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Refused 0 Y ® N 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDA. 0 EWES ❑NMV 0 NOV ❑DV
!1 9 8 6 Chevrolet Equinox 2019 00-NONE ,i"j t2"-_, DUETO CRASH ❑ Ig 2 73
o 13-UNDER CARRIAGE �a} 2 FIRE 0 ® U2 C
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F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 0
POINT OF s i4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR all,,,
FIRST CONTACT 6 7 - S •If Yes.See Sidebar C
Elgin IL 60123 0 1 0 DY41744 IL 2026 I 0
IL D 2G NAXJ EV7K6261170 Direct Auto Insurance ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 20151743567 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER®N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 1 04,11 l2026 03 01 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 03 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, ARREST NAME / / ID PM '
o N El 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
t 2 El NAMEAM
x- 7 1 / ❑❑PM ❑Unknown work zone type
30
U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
566-Lopez, Eric 101 - r i ❑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 -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ri L ® } (example:shuttle or charter bus):or X
L A J 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____.i 4. Isusedordesinatedtotrans transport passengers,including N
} } } g po fic p rs,includi the driver,
for direct compensation(example:large van used fors cific purpose):or
O
L____a____. 1 - 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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r placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
mil_ JUNK
ADDRESS 0
D
I) I -{ice, 0
Not To Scale f CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
❑ Yes II No ❑ Unknown 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
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. Z
White Redw
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE