HomeMy WebLinkAbout2026-00024171 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004223770'
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 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 El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00024171 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
W CHICAGO ST Elgin 01:56
® ❑ RELATED ' V 0 N 04 29 2026 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W S STATE ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR IR SLOW 5 Ch
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROM TOWED U1 0
Unknown Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
f� !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 5 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
s 4 COM VEH 0 E!
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[s !I,_ 1 00
~ 0 9 0 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
6 UIK ❑Y ❑N U2 I—
SI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same UIK 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
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N DRIVER 0 PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 Nuv 0 NCv 0 Dv CIRCLE NUMBER(S) U1
!1 9 8 3 FROM TOWED
Dorado MfgEArtder 2007 00-NONE O,' t2 "_, DUE TO CRASH ❑ 29 73
0 Yr 13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C
II
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s FIRST CONTACT 11 7�-il 6 I1:,_5 4 CO( Mes VEH.See Sidebar❑ NI U1 CO
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H ELGINZ IL 60120 0 1 0 M172657 IL 2026 REAR
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IL B 7 1 N9MNAC677C084089 Self Insured ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Pace Bus Terminal Self Insured BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U2 0
996
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1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
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N 1 CD 11 1 04/29 /2026 01 56 ®PM in a Work Zone? ®N DIRP >
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
v 1 T 2 0
20 2 1 / 0 PM El Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / El PM
o N ® 11 1 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
t 2 ❑ 35
ARREST NAMEAM
x- T ❑PM 0 work zone type U1
/ / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 — ❑AM Workers present? ❑Y 35
1573-Bea�Iey. Maltese 601 / / ❑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
' combination):. Hasor more than pounds(example:truck or truck trailer 1. Has a weight rating10 000 � -<
r }----r----, I I - r INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
i_ I I - } (example:shuttle or charter bus):or
- ------I----; vr?CI e''rsr. I I transporting rtig employees inthe course of 5 or fewer passengers
e e mplanoyment example:employee a contract
X
} } } po ng employment
n .t. i I transporter-usually a van type vehicle or passenger car):or co
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 ge ng N
} } } g Po passen rs,includi [he driver,
. for direct compensation(example:large van used for specific purpose):or O
L L--_-a----. yL 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
i I- CARRIER NAME Z
II g ADDRESS O
-
1
11(14
�n
I I CITY/STATE ZIP
g
- MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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? A
❑ Yes II El 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'; ❑Yes 0 No 2
TRAILER VIM 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE