HomeMy WebLinkAbout2026-00021537 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III III 11 IIII
UHI U� I� liii II III 1DUIHI
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004206521
u, 9 u21 3 4 1 IA 99 U2 1 u,99 U2 1 u,99 U2 1 1 10 U1 99 U2 -3-1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00021537 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
S RANDALL RD EIIn
® ❑ RELATED ®Y ❑N 04 18 2026 09:52 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo 1 day 1 yr ❑PM FLOW CONDITION m
FT!MI N E S W SOUTH ST COUNTY PROPERTY ElY ® N DOORING El #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
/ / FOR DAMAGEDAREA(S) f4tair TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 O <
9 9 SYSTEM IN
Y g ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑ ❑N El VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1�a 1i,_ 1
It.
9 0 FIRST CONTACT 99 7 •ReAji _ COM VEH 0 j$J 5 *II Yes.See Sidebar U1 0
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'Et Y°N❑l N D Ai
m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 N v 0 Dv
9 9 9 Chevrolet Blazer 2020' 00-NONE ,�_"j t2 -_, DUE TO CRASH ❑ 2
0 Yr 13-UNDER CARRIAGE 10'1 2 FIRE 0 El U2 C
c ®
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value g g
POINT OF 8 1 �I" 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR :J 5
FIRST CONTACT 5 7 _,SOS •(ryes,See SidebarC
ELGIN IL 60123 0 1 0 EZ65251 IL 2026 I g (I)
IL D 0 3G N KBKRSXLS713995 State Farm ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3440450SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 9 04,18 /2026 09 52 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 18 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING • + ) - ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME ! 1 ID PM '
o N El 11 40 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
AM15
7r 2 ❑ / 1 ❑❑PM 0 Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 15
1530 Soto.Oscar 807 , / ❑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
GO 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 1 - } INDICATE NORTH combination):or -I
r I r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
r r X
< < I Unit 2 I 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
rter-
enger
or c0
L L.___a.._.� I �l I 42lsuosedordesgnatedto tranlly a van type sport betweeicle or n9a d15rpassen rs,includingthedriver. fn
} } for direct compensation(examp large van used for specific purpose):or O
--- J i i 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
Weld?Rd placarding(example:placards will be displayed on the vehicle). X)
D
CARRIER NAME Z
Z
r I I
1 - • __ ADDRESS D
C)
, , ,. ,.
CITY/STATE/ZIP g
_ MOTOR CARR.ID 0 Interstate El Intrastate
TI ,S R ❑ Not in Comm./Govt. Not in Comm./Other0
USDOT NO. ILCC NO.
andall?Rd mxi
• Source of above z
. ❑ Yes 0 No 0 Unknown M
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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