HomeMy WebLinkAbout2026-00031233 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY N OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202612026-00031233 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ❑Y ®N 06 01 2026 ®AM ❑YES N NO U1 —<
551 N MCLEAN BLVD Elgin PRIVATE mo /day/yr 03:31 ❑PM FLOW CONDITION m
®!MI ON E s w n mclean Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD DO
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❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18: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 0
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 4 <
9 9 SYSTEM IN O ENGAGED O 15-OTHER 9 76-TOP 3 0 ' _
❑Y (Z)N ❑UNK VEH. ATCRASH 99-UNKNOWN `DistractionValue 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 1-( 4 C.OM VEH 0 El 1 0
I— 0 9 0 FIRST CONTACT 1 7_; _5 *IIYes.SeeSidebar U1
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TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
NA ❑Y ❑N U2P. m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NA 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ElY ElN 99 G0)
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 Dv
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❑Y 10 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistract Dn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:, 4 COM VEH El U1 CO
FIRST CONTACT 11 7� , _5 •(ryes.See Sidebar
n ELGIN IL 60123 0 1 0 EZ22458 IL 2026 RFJ
IL D 5N1ANONW6CC508863 Progressive ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 988230768 BAC
$
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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 9 06/01 /2026 03 31 ®❑AM
in a Work Zone? NCI N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 15 99
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ) ❑PM- ❑Construction >E
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, u ARREST NAME / / ID PM
N -1 1 UtilitySLMT
o SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
AM u, 45
t 2 El ARREST NAME 06/01 12026 03 31 [M PM ❑Unknown work zone type
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n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 35
1549-Brown. Bryan 602 — r / ❑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 unitshave been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
- ADDITIONAL UNITS FORMS.
r ----r••--, , I ; 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 truckrtrailer -<
i- ;.---_r_---; I INDICATE NORTH combination):or —I
pr
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I - (example:shuttle or charter bus):or 0
I- L.___A.._.� 3. Isdesgnedto carry 15or fewer passengers and operated bya 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
L }-----}----; - } I- 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver.
Eagle/Road l �I a for direct compensation(example:large van used for specific purose):or
L L___-a..... N - L L � ,_ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
- — — ''�j — — placardig(example:placards will be isplayed on the vehicle). XI
° D
Not TO Scefe , CARRIER NAME Z
y 9 Btu ADDRESS O
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CITY/STATE/ZIP
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- i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I R ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
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I x C
, _Y_ _. USDOT NO. ILCC NO. m
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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?
❑ Yes II No ElUnknown 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' 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' 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other t Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE