HomeMy WebLinkAbout2026-00030735 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and ror Tow Due To Crash
0 AMENDED YR 2026I 2026-00030735 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
DWIGHT ST Elgin12:25
® ❑ RELATED ®Y 0 N 05 29 2026 DAM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR El SLOW 15 u)❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
Mao TOWED U1 Q
NAME(LAST,FIRST,M) DOSE. DOROTHY.J. mo yr Volkswagen Beetle 2019 �00-NONE 11_ 12 `_, DUE TOCRASH ® ❑
�.:!UNDER CARRIAGE 101 !. 2 FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 4 ❑Y ®SNE❑ 15-OTHER
UNK VEH. O ATCRASHD O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it a �i,4 COM VEH 0 j$J 1 C)
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 1 O7 _; __5 •If Yes.See Sidebar U1 0
Z EHI89AR IL 2026
TELEPHONE
IL D 0 3VK5DAAT3KM506637 STATE FARM ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Same 3984157-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 i v ❑Dv
�1 9 8 5 Hyundai Santa Fe 2014 00-NONE O1 01 , DUE TO CRASH 0 2
0 13-UNDER CARRIAGE 10 I Ic 2 FIRE ❑ ® U2 C
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M 1 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .i�.._ 4 C.OM VEH ❑ ® U1 CO
FIRST CONTACT 11 7 _5 •IfYes.See Sidebar C
ELGIN IL 60120 0 1 0 ES95494 IL 2026 I Si)0
IL D 0 SXYZT3LB8EG 178916 GENERAL AUTO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 1 B-I L-9050385 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPONDER❑ U1 =
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(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 occur 0 Y U2 Z
N 1 ® 11 4 51 r 91 r026 12 25 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
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2 ❑ 18 99 ) r ❑PM• ❑Construction >E
Z3 ❑ Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
a NICHOLS. KEVIN. D. 6-303-A 374001378 r r PM
-, ARREST NAME ❑
o u 1 ® 1 1 4 �(CITATIONS ISSUED ❑PENDING TIME • ❑Utility SLMT
o N SECTION CITATION NO. ROAD CLEARANCE 0 AM 3O
t 2 ElARREST NAME N ICHOLS. KEVI N. D. 11-402-A 374001379 r r El Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
374-Rizzu-o. Michael 401 71 112 /26 01 30 ®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
° 'R AT 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
INDICATE NORTH combination):or
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 tocarry 15 or fewer passengers and operated a contract carrier O
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es pa g pe
Not To Scale 1 . } . transporting employees in the course of their employment(example:employee73
transporter-usually a van type vehicle or passenger car):or w
L I-----}----; ovnawr,ev I - } } } 4. Is used or designated to transport between 9 and 1 ssen rs,including[he driver,
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for direct compensation(example:large van used fors cific purpose):or
MI, ) 0
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< <____a____. {lam. _ L t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M
1 �—�r placarding(example:placards will be displayed on the vehicle). XI
D
T CARRIER NAME Z
'or ADDRESS
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ICITY/STATE/ZIP g
_ i. MOTOR CARR.ID 0 Interstate 0 Intrastate
❑ Not in Comm./Govt. 0 Not in Comm./Other 00
----'Y----1 - USDOT NO. ILCC NO. C
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 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
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
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
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE