HomeMy WebLinkAbout2026-00027967 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004236658
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00027967 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m® ❑ RELATED ❑Y ®N 05 17 2026E�IAM El YES ElPRIVATE NO U1
S STATE ST Elgin mo /day/yr 03:21 ❑PM FLOW CONDITION Ill
01RD/MI• O E S W East Route 20 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Cl)
Kane HIT&RUN I2J V ❑ N WITH VEHICLESOT,
INVLD DO
STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Unknown.O. Unknown Unknown 00-NONE 'It. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 4 <<n
9 SYM IN ENGAGED
9 ❑Y ❑SNE !UNK VEH. 9 AT CRASH 9 ®15-OTHER UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL 6 4 COM VEH 0 Ea 1 0
1 . Unknown Unknown 0 9 FIRST CONTACT 99 7_; __5 *II Yes.See Sidebar U1
ZUNKNOWN Unknown REAR
TELEPHONE
UNK. UNKNOWN unknown ❑Y ®N U2 I'
in 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
RESPONDER D
Refused ❑Y El 99 G0)
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 ivy 0 Ncv 0 DV
/1 9 8 6 Dodge Ram 1500(pickup) 2021 00-NONE ,�_` t2 "_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE o 1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16•TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'i. .!,_4 COM VEH ❑ ® U1 W
FIRST CONTACT 8 7 _,L_5 •• •If Yes.See Sidebar C
Racine WI 53403 0 1 NA4133 WI 2027aR 0 Si)
WI D 1 C6SRFFT4MN674218 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 1075536SFP49 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 04 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 CO 11 9 05/17 /2026 03 20 ®❑PM in a Work Zone? ®N DIRP co
1 I 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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v 1 2 0 25 2 / / ❑PM ❑Construction X
Z 3 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a, ARREST NAME / / El PM '
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
N SECTION CITATION NO. ROAD CLEARANCE TIME
o El
AM 30
t 2 El ARREST NAME 05/17 /2026 04 00 MPM 0 Unknown work zone type u,
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 30
498-Johnson.Andrew 701 341-Cox / / ❑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,U:nil:R 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, 0 ..:. A CMV is defined as any motor vehicle used to transport pasers or property and: Z
Has a weight rating more than 10,000 pounds{example: or truck trailer
1.
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i- }--_.r-_--; } combination):or —I
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
X
- ------I----; I transportinggemployees lloyeeo slin the course of 5 or fewer passengers
e ersnanodyment(example:employee a contract
SNot To Scale l } F } transportr-usually a van Type vehicle or passenger car): r w
L L.___a____� I } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
C
} } for direct compensation(examp large van used for speific purose):or 0
I. i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a I placarding(example:placards will be displayed on the vehicle).
p CARRIER NAME Z
J ` ADDRESS 0
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EEMIL720 0
--AP: _ • CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I r ❑ Not in Comm./Govt. Not in Comm./Other O
n r r 0 o
--- --4. f I - USDOT NO. ILCC NO. m
xi
Source of above Z
. own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
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 0 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
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: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE