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HomeMy WebLinkAbout2026-00027782 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M UHI U n� III ���� 111111111H DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�004234496 u, 1 U21 1 1 1 U1 6 U2 1 U, 1 u2 1 U, 1 u2 1 1 15 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00027782 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ®Y 0 N 05 16 2026 ®AM ❑YES ®NO U1 -< CENTER ST Elgin09:01 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W FRAM KLI N ST COUNTY PROPERTY ❑Y 2�1 N DOORING ❑y #OF MOTOR ®SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑ICU ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n 0 5 ! yr Ford Explorer2025 00-NONE DUE TO CRASH ❑©1 1z _ E 13-UNDER CARRIAGE 10 1 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 1 r<rl M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & it 6 �i COM VEH 0 0 1 n F. FIRST CONTACT 11 7___--_;__5 *lives.See Sidebar U1 0 V Z E LG I N IL 60120 0 1 0 M P26137 IL 2026 REAR TELEPHONE IL D 0 1 FM5K8AC2SGB51581 Charter Oak Fire Insuranc ❑Y ®N U2 10 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 8109160P901 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 6 0 N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑Nuv 0 KKv ❑DV '1 9 9 1 Jeep(after 198;i)ind Cherokee 2001 00-NONE 11-.. t2...0 DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 10I 2 FIRE ID ElU2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y lYi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 1l, COM VEH D ® U1 CO FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar H ELGIN Z IL 60120 0 1 0 R178518 IL 2026 REAR C M IL D 0 1J4GW48N81C599485 Geico ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 6173867471 BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occAur 0 Y U2 Z co N 1 CD 11 1 05(16 /2026 09 03 ®❑PM in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C) 9-, 1 T 2 ❑ 05 2 ( / ❑PM ❑Construction * Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' 1 ® _1 1 1 ❑CITATIONS ISSUED ❑PENDING • UtilitySLMT NNO. ROAD CLEARANCE TIME o ❑ SECTION CITATION AM u, 30 r 2 ❑ ARREST NAME 05(16 /2026 09 03 j PM ❑Unknown work zone type n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1566-Polovin. Matthew 102 386-Lynch , 0 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 -< i- }____r__--; } comWrtatlon)or INDICATE NORTH BY ARROW c Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or 3. Is designed to carry15 or fewer passengers and operated a contract carrier ` } } } transporting employee In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w 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 • "'; Unit 'D __ .- i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires ID- _�:'= placarding(example:placards will be displayed on the vehicle). XI cMteritt D I l CARRIER NAME —I ADDRESS D .I. ‘I. . 4 Ili g moklln CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate El Intrastate I I T I ❑ Not in Comm./Gout. 0 Not in Comm./Other i— --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 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 VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 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/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE