HomeMy WebLinkAbout2026-00025971 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00025971 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mLYNCH ST Elgin03:21
® ❑ RELATED ❑Y ®N 05 07 2026 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W W H I G H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER t] PARKED ❑DRIVERLESS ❑ PED ❑PEDAL a EWES a uuv a!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
Janiec.Anthony. . mo
!1 9 7 8 General Motors 2019 00-NONE 11_ 12 `_I DUE TO CRASH ❑
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13-UNDERCARRIAGE 10i I! 2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 02 m
M 2 SYTM IN ENGAGEDTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 9 16•TOP® `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 6 �I COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 3 7_• -_5 *II Yes.See&debar U1
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TELEPHONE
KY D 0 3GKALVEX7KL260565 Geico El ®N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Same 6188-19-89-61 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 0
❑ DRIVER X. PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑M/v 0 NOV a Dv CIRCLE NUMBER(S) U1
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0 13-UNDER CARRIAGE
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F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- . 6 j1:,_4 COM VEH ❑ ® U1 03F=
FIRST CONTACT 6 7�'_,�_5 •(ryes.See Sidebar
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 966815967 BAC
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Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 05,07 l2026 03 22 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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2 0 20 2 1 1 ❑PM ❑Construction *
Z3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
o1 ® 11 1 ARREST NAME Janiec.Anthony. R. 11-709-A W1569000069 / ! El PM SLMT
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0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
30
ARRESTNAMEAM
Tr 2 ❑ ❑❑PM 0 Unknown work zone type U1
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n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? D Y 30
1569 Jaimes.Julian 600 320-Cox r ! ❑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 truck trailer -<
` ` -'- ' • INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ® - } (example:shuttle or charter bus):or
< <----- -•--; l - transporti3. Is ng employened to es 5 or fewer inthe course passengers
engers and operated
example:employeecontract I
l } r }
transporter-usually a van type vehicle or passenger car):or �
4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; ur+k - } } } g po pafic p rs,):or i the driver,
a i . i i for direct compensation(example:large van used for specific purpose):or �
tr L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
t� - CARRIER NAME Z
ADDRESS 'n
CITY/STATE/ZIP
\ Not To Scale I MOTOR CARR.ID 0 Interstate 0 Intrastate
r ` ❑ Not in Comm./Govt. Not in Comm./Other
` USDOT NO. ILCC NO. T.
XI
Source of above z
. ❑ Yes ❑ 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
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
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
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE