HomeMy WebLinkAbout2026-00025751 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and f or Tow Due To Crash YR 202612026-00025751 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 06 2026 ❑AM ❑YES ®NO U1 -<
CAPITAL ST Elgin03:52
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W ALFT LN COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 /
yr
Esposito. Diana. L. Volkswagen Jetta 2019 00-NONE ,, • 12 , DUE TO CRASH ❑ EN E
13-UNDERCARRIAGE fat 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SY4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL 6 �i 4 COM VEH 0 ZgJ 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.SeeSidebar U1
Z DE318 IL 2027 REAR
TELEPHONE
IL D 0 3VWG57BU6KM069443 Horace Mann ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 65000141010101 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 c
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row
/1 9 8 6 Ford Mustang 2025 00-NONE 11 . t2 "_, DUE TO CRASH ❑ C 2
0 13-UNDER CARRIAGE I 2 FIRE El El U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'i. .!,_4 COM VEH ❑ ® u1 CO
FIRST CONTACT 9 7L_5 ••If Yes.See Sidebar C
Hampshire IL 60140 0 1 0 DZ37306 IL 2027 I 0 Si)
IL D 0 1 FA6P8CF9S5416290 Allstate ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 856920960 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (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 ❑Y U2 Z
N 1 El 11 1 05,06 l2026 03 52 ®FM AM in a Work Zone? NJ 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 �
0
2 20 99 1 / 0 PM ❑Construction *
Z3 ❑ ElCITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o1 ® 11 1 ARREST NAME Esposito. Diana. L. 11-708 489000553 / ! El PM SLMT
o N •
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
25
t 2AM
7 ❑PM ❑Unknown work zone type U1
El NAME / 1 ❑
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
489-Reynolds.Allison 900 320-Cox 06 , 16/2026 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.
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 -<
c ` '' -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N (example:shuttle or charter bus):or C
Not 1b Scab 1 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
i [ ii } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
C
L L.__-a-_--J ,��1i_ I. } •4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
� & } } for direct compensation(example:large van used for speific purose):or O
__ QQQrrr"'���►►► i. < i. ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
1 1 1 placarding(example:placards will be displayed on the vehicle). ,Zmt
emw, � [ir CARRIER NAME Z
ADDRESS 0
V)
CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-------- --: - USDOT NO. ILCC NO. rn
XI
Source of above z
. 0 Yes 0 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
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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. w
White Red
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE