HomeMy WebLinkAbout2026-00022264 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II I 111 IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00022264 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 04 21 2026 ❑AM ❑YES ®NO U1 -<
N GROVE AVE Elgin mo /day/yr 04:43 ®PM FLOW CONDITION Ill
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010 ®/MI N E p w FRAN KLI N St COUNTY PROPERTY ❑Y 21 N DOORING ❑Y #OF MOTOR IR SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —1
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 Icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n
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1 2 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn
F 2 4 SYTM❑Y ®SNE El UNK VEH. 0 AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH 0 j$J 1 0
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ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Ir Ves.See Sidebar Ut
Z CK75401 IL 2027 Ismi
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IL D 0 19XFC2F73JE034816 State Farm ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 3699553-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
Eg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMNV 0 V 0 DV
/1 9$4 Porsche Standard 2008 00-NONE 'o,I t2 (,-2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N El UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® Ut CO
I— FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.SeeSidebar C
ELGIN IL 60120 0 1 0 PINON-WS IL 2027 I AR Si)0
IL D 0 WPOAA29898U761247 Travelers ❑Y ®N RDEF X1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 pinon. Brian.J. 6182991672031 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 6 03 / M 13 3 0 1 0
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/ / #OCCS D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 1 41 , 11 /026 04 45 ®AM in a Work Zone? ®N DIRP 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
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2 0 28 18 / 1 0 PM- ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Almanza.Alexis. D. 11-601 S1570-000034 / / ❑PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
El AM
t 2 El ARREST NAME 41 /11 /026 04 43 ®PM El Unknown work zone type U1 3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1570-Tomlin. Eli 102 320-Cox 51 , 21 /026 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
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Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
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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?
❑ 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
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Form Number 0
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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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 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE