HomeMy WebLinkAbout2026-00025676 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004224460
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00025676 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 7
® ❑ RELATED ❑Y ®N 05 06 2026 ®AM ❑YES ®NO U1 -<
S MCLEAN BLVD Elgin 09:54
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION M
FT/MI N E S W LILLIANST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
FOR DAMAGEDAREA(S) FRO 1 TOWED U1 Q
LIZARD!. KELVIS.A. 0 2 /
yr 13-UNDER CARRIAGE 10 I , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 5 r<11
M 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a 4 COM VEH 0 j$J 1 0
~ ELGIN !L 60123 0 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1
ZEM69865 IL 2026 REAR
TELEPHONE
IL D 0 5NPDH4AE2GH685014 KEMPER ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12RA000018407 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER
W g DRIVER 0 PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 ivy 0 Ncv 0 CIRCLE NUMBER(S) U1
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1 9 9 0 Lincoln MKC 2017 00-NONE 'o r t2 ( 2 FIREocRASH ® U2 2 C
o Yr 13-UNDER CARRIAGE0
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TtOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'i- 6 11;,=4 COM VEH ❑ ® U1 C
FIRST CONTACT 8 Q __,�_5 •lryes,SeeSidebar
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ELGIN IL 60123 B 1 0 FS22611 IL 2026 I 0 N
IL D 0 SLMCJ2C9XHUL63080 PROGRESSIVE ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 867914172 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N u1 =
(UNIT) (SEAT) (DOB! (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 02 / M 2 3 0 1 0
m
/ / #OCCS D
/ / UI 2 D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 05,06 �2026 09 54 ®❑pM in a Work Zone? ®N DIRP co
1 F PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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2 ❑ 2 99 1 1 ❑PM ❑Construction
Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a LIZARD!. KELVIS.A. 11-906 W244-1853 1 r PM '
-, ARREST NAME ❑
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
F 2 ARREST NAME AM
1 r ❑❑pM ❑Unknown work zone type U1
n T El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID - ❑AM Workers present? ❑Y 30
244-Blomberg. Michael 601 r r El 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.
L
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
I ADDITIONAL UNITS FORMS.
Nd To Scale ,
r ----r••--, , 4 ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
iS I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- ;.--__r-_--; I ( INDICATE NORTH combination):or —I
71
,,,,+ _ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
�-'� xw+e.wav�x } (example:shuttle or charter bus):or 0
} r r r
; 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
. }i. } } transporting employees In the course of their employment(example:employee73
J transporter-usually a van type vehicle or passenger car):or C
L }-----}----I. 0 Z - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver.
LL1 for direct compensation(example:large van used fors specific purose):or O
L -a V - t i. i i. ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
M placarding(example:placards will be displayed on the vehicle). X/
-I
CARRIER NAME Z
ADDRESS 0
w
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
XI
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
cn
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE