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HomeMy WebLinkAbout2026-00030805 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 II III fl NI 111 ill 11 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004259549- u, 1 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 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 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) (8:1B Injury and/or Tow Due To Crash El AMENDED YR 202612026-00030805 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN STATE ST EIin 07:04 ® ❑ RELATED ' V 0 N 05 29 2026 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W TOLLGATE RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FRO9ir TOWED U1 O Mosier.Christopher. 0 3 / yr 13-UNDER CARRIAGE ©it),I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2[230 m M 2 5 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a 4 COM VEH 0 j$J 1 0 m F• B 1 0 FIRST CONTACT 12 7 ;1 _5 *If Yes.See Sidebar U1 ee.z IWPL55 FL 2026 Ismi TELEPHONE TN D 0 2FMPK3J93HBC41323 Progressive ❑Y IlN U2 I' IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 65 9 IAFONTAINE.CH ERE.J. 974513510 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 g DRIVER 0 PARKED 0 DRIVERLESS 0 FED ❑PEDAL 0 EWES 0!My 0 NCv 0 DV /2 0 0 2 Honda Pilot 2006 00-NONE 0-1 QI•0 DUE TO CRASH rg ❑ 2 73 o 13-UNDER CARRIAGE 10( ) 2 FIRE ID ® U2 C M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0 POINT OF 8 i1�I 4 COM VEH ❑ ® U1 co N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B -5 •• •(ryes,See Sidebar i WEST DUNDEE IL 601 1 8-351 2 B 1 0 CB37087 IL 2026 I 0 C IL D 0 5FNYF28576B001251 Geico ❑Y ®N RDEF .73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 6127095039 BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 10 / F 2 5 B 1 0 m / / #OCCS > / / UI 2 m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 El 11 05/29 /2026 07 04 ®PM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C1 T o", 2 ❑ 2 99 / / ❑PM• ❑Construction Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM Maintenance U2 ❑ a1 ® 11 1 ARREST NAME Mosier.Christopher.g. 11-901-A 1563-213 / / ❑PM ' o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,...,Utility SLMT r 2 ❑ ARREST NAME AM T / / PM ❑Unknown work zone type 45 U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 1563-Rodriguez.Carlos 501 06 , 16/2026 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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` -' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - } (example:shuttle or charter bus):or X I r I ,,,,,,R..;,...,!, . 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 I 1- L----------� I ® - i. } } } transporting employees in the course of their employment(example:employee X r transporter-usually a van Type vehicle or passenger car):or w L L.___a____� 1 } } } 4. Is used or designated to transportbetween9and15passengers,includingthedriver. 0 for direct compensation(example:large van used for specific purpose):or . / 4I i t *�.ir+► } } } t 5. Is an vehicle used to transport an hazardous material(HAZMAT)that requires f ` placarding(example:placards will be displayed on the vehicle). m / 0 / r i w I A. ' \ CARRIER NAME Z �� I 'i+k - ADDRESS 6) T. C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ---"-1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 Blue 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE