HomeMy WebLinkAbout2026-00029379 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202612026-00029379 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 23 2026 DAM ❑YES ®NO U1
ST CHARLES ST Elgin03:49
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 3 co
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD DO
U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRCf'rr�DUE TO CRASH TOWED U1 0KAPLAN. LI N DA.J. 1 2 /
yr 13-UNDER CARRIAGE FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 2 m
F 2 SYTHER
5 ❑Y El EDUNK VEH. 0 AT CRASH M IN ENGAGED 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 6 �i COM VEH 0 j$J 1 0
H 1- PINGREE GROVE IL 60140 0 1 0 FIRST CONTACT 2 7_:1 -_5 *II Yes.See Sidebar U1
ZDZ74703 IL 2026 REAR
TELEPHONE
IL D 0 YV4A22PK5K1422308 STATEFARM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3021090 SFP 13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑DV
yr Nissan Rogue 2018 Do-NONE (D0'0 DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE 10,i I.. 2 FIRE ID El U2 C
c
F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value g g
s I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
FIRST CONTACT 12 YLid 6 I` .5 •CIf OM Yes.VEH See Sidebar❑ ® Ut CO
WEST CHICAGOZ IL 60185 0 1 0 CS25911 IL 2026 REAR C
9 Cl)
IL D 0 5N1AT2MT5JC750467 FOREMOSTA FARMERS INSURA ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
Same A7999771640 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(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 ❑Y U2 Z
N 1 ® 11 1 05,23 ,2026 03 49 ®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 C)
2 0 2 28 05,23 (2026 03 50 pM
1 ® • ❑Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
—a ARREST NAME 05(23,2026 03 55 ®pM '
,
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
r 2 ❑ 15
ARREST NAMEAM
x- 7 / / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
❑Y
2 2 3 ❑ ❑AM Workers present? 40
1516-Mancera. Maria 401 - ( / ❑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
I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I - (example:shuttle or charter bus):or
X
oYrt R_VI t * 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
utzI I - } } } transporting employee In the course of their employment(example:employee X
is I transporter-usually a van type vehicle or passenger car):or w
C
,
_ }-----;----;, Unit- !ii.' ►-1--1 - I.
} } } •4. Is used or designated to transport between 9 and 15 passengers,including the dryer, (I)for direct compensation(example:large van used for specific purpose):or o
T � i i .. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires III
a placarding(example:placards will be displayed on the vehicle).
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_ 1::.CO CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. Form Number m
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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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. y
White Black
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: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE