HomeMy WebLinkAbout2026-00027708 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II UHI UU II III I IIIU 111E11111
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X0014246716
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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 ❑5501-51,500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00027708 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
® ❑ RELATED ❑Y ®N 05 15 2026 ❑AM ❑YES ®NO U1 -<
LILLIAN ST Elgin PRIVATE mo /day/yr 10:11 ®PM FLOW CONDITION Ill
I O 0/MI N E 0 W Mclean Blvd COUNTY PROPERTY ❑Y MN DOORING Ely #OF MOTOR 0 SLOW 1 (/)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 9 /
Honda Civic 2001 00-NONE „ O i_1 ouE ro CRASH ® ❑
13-UNDER CARRIAGE tU i , 2 FIRE ® ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 I'T7
M 2 5 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 99-UUNKNOWN THER976•TOP3 `Distraction Value 6 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL a 4 COM VEH 0 El 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: _5 *II Yes.See Sidebar U1
ZFQ62365 IL 2026 REAR
TELEPHONE
IL D 1 HGES16571 L013368 ALLSTATE ❑Y ®N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 Same 942328805 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 Kcv 0 Dv
/1 9 y $8 Buick Enclave 2014 00-NONE 11_' 12..-_, DUE TO CRASH 0 C 2
.. 13-UNDERCARRIAGE ta;i c. 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
a`
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF T CONTACT 8 7 Hj®_I!_5 CIO MVEH See Sidebar
0 U1 CO
= ELGIN IL 60120 0 1 0 CX58901 IL 2026 C
IL D SGAKVBKD4EJ201862 STATEFARM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 1 99 9 Same 3664410SFP13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 02 /
:A
/ / UI 2 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 05/15 /2026 10 11 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 40 03 05,15 /2026 10 13 pM
® • ❑Construction
Z 3 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
-a ARREST NAME 05/15/2026 10 16 ®pM '
,
I 11 1 ❑CITATIONS ISSUED ❑PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
ElUtilit y
t 2 El ARREST NAME 05/15 /2026 10 40 0 PM El Unknown work zone type U1 0 AM 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? 0 Y 30
1553-Jentsch.Clarissa 701 / / ❑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- }-- -- --; 1 I y � f combination):or
_) INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} j 1 3 - } (example:shuttle or charter bus):or
X
L A I 4 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
— — } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ -. I. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for cific ur mdudi the driver,
y Pe ( P 9 Pe purpose):or O
L L--_-a-___.I -k t - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M
placarding(example:placards will be displayed on the vehicle). XI
414 G *skit* --
1 i I CARRIER NAME Z
1 �I ADDRESS O
T.
I I I rn
0
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- ----1 - USDOT NO. ILCC NO. rn
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 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Beige Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE