Loading...
HomeMy WebLinkAbout2026-00029105 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III 11 IIII IIIIII U I� liii 11I1 llfli �HI�D DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004243494 u, 1 U21 3 4 1 u, 8 U2 1 u, 1 1_12 1 u, 1 U2 1 1 12 u, 13 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00029105 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 05 22 2026 ®AM ❑YES ®NO U1 -< ROUTE20 HWY Elgin mo /day/yr 06:16 ❑PM FLOW CONDITION Ill _ I 0 ®!MI N E S © Randall Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 15 u) Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n FOR DAMAGEDAREA(S) FROM TOWED U1 O Sha an. Beena 1 1 / yr 13-UNDER CARRIAGE 101 2 FIRE 0 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 5 <<T1 F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 �i 4 COM VEH ❑ 0 1 0 ~ Hanover Park IL 60133 0 1 0 FIRST CONTACT 1 7_;- -_5 *II Yes.See Sidebar U1 Z BT27058 IL 2026 TELEPHONE IL D 2T2BZMCA6KC187551 Traverlers ❑Y igiJ N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 6166913552031 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused El El 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑row 0 I v ❑DV '1 Yr 9 9 1 Jeep(after 196�)npass 2021 00-NONE 111' t2 (,-2 FIRED CRASH ❑❑ U2 2 C o 13-UNDER CARRIAGE c M 2 4 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN •t •OistraellonValue 0 - POINT OF 8 ll 4 COM VEH ❑ 0 Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR & FIRST CONTACT 7 Q ,�_5 •If Yes.See Sidebar Lake In The Hills IL 60155 0 1 0 EJ46532 IL 2027 REAR0 Si) IL A 7 3C4NJ DABXMT584331 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 1875053SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 3 03 / M 2 3 0 1 0 m / / #OCCS D 71 / / U1 1 D / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z N 1 ® 11 1 05!22 /2026 06 16 ®❑PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 20 28 ! / 0 PM ❑Construction * 3 R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Shajan, Beena 11-709-A 298001391W / / El PM SLMT o N - ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility r 2 ❑ ARREST NAMEAM T / / pM El Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 298-Lopez, Mirko 901 331-Ziegler ! / 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. i 0 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 -< c ` -' -' r INDICATE NORTH combination):or —I i_ i.. -:. \\\\\\\ BY ARROW 2 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 O - } } } transporting employee In the course of their employment� (example:employee � � transporter-usually a van type vehicle or passenger car):or w L -----}----; (;'�'i - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, w �r? for direct compensation(example:large van used for specific purpose):or O D i I. L 5 Isanyvehde used to transport any hazardous material(HAZMAT)that requires ii' N =N i> placartling(example:placards will be displayed on the vehicle). �;1. _ D �/ N. 'y CARRIER NAME XI rnlot To Scale 1 ADDRESS 'O r r T 1 ....) E U) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate tZand4ill?Rd. 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 ----------1 - USDOT NO. ILCC NO. C m XI Source of above z . ❑ Yes II No ❑ Unknown 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 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 White Blue 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE