HomeMy WebLinkAbout2026-00024701 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 11111110111101 1lI100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004223 67-
u, 1 U21 1 1 1 U,99 U2 1 U, 1 1_12 1 U,99 U2 1 1 9 U1 99 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 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)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00024701 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
1210 HIAWATHA DR El 07:03
® ❑ RELATED ❑Y ®N 05 01 2026 DAM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Unknown Unknown Unknown 00-NONE „ 12 , DUE TOCRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
< > 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
$ 4
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s �i, COM VEH 0 Ea
_5 1
~ 0 1 0 FIRST CONTACT 99 7_; *IIYes.SeeSidebar U1
0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
unknown 0 Y 0 N U2 I-
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N0 N 0
❑ DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 Dv
yr Ford Edge 2016 00-NONE O t2'"_, DUE TO CRASH ❑ 21 1 a7
o 13-UNDER CARRIAGE 10 I 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16
® -TOP 3 9 0 X
a ❑Y ❑N UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value
-
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S i�'`_4 COM VEH 0 ® Ut CO If Yes.See Sidebar
FIRST CONTACT 11 8 7 _, _5 •
H FM39949 IL 2026 REAR0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2FM PK3J88G BC57135 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 HOGDAHL. DAVID.T. 3614063-SFP-13 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)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 18 1 05,01 l2026 07 03 ®PM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + r 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
-a, ARREST NAME / / 0 PM
o N ® 11 1 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
25
t 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 00
1567 Muehl.Claudia 201 , ! ❑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: D
p Unit 2 Z
` 1 smore thantruck or truck trailer
i- �____r____; ;lei combination):or rating10,000pounds{example: —I
rat INDICATE NORTH 21
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ II.
I�I _ (example:shuttle or charter bus):or 0
1: ;,
. --I—
I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
Unit 1 - } } } transporting employees in the course of their employment(example:employee 23
transporter-usually a van type vehicle or passenger car):or CO
L L.___a._._� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
` h.""_a_"""i Ford?Ave - ` _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires 'D
rn
.." placarding(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP g
Not To Scale •
MOTOR CARR.ID 0 Interstate 0 Intrastate
-I-I I I 0 Not in Comm./GaA. Not in Comm./Other
0
;_...Y._._ USDOT NO. ILCC NO.. 01
m
XI
Source of above z
. • m
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 E
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes iO No El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No -
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
ill
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE