HomeMy WebLinkAbout2026-00031579 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI U� I� III fl11 I11I11HH1ODD
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004259555
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® 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 ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and f or Tow Due To Crash YR 202612026-00031579 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH rn
N MCLEAN BLVD Elgin06:29
® ❑ RELATED t3I Y 0 N 06 02 2026 ❑AM ❑YES 0 NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
_
FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED 0 DRIVERLESS Ig) PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGED AREA(S) FROf4r TOWED U1 0St.Clair. Isaac 0 1 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 U2 2 Elm
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�S 4 COM VEH 0 0 1
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 00 7 ; _5 *II sees.See&debar U1
0
REAR
c Z E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
( No Insurance ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 52 1 Same No Insurance 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NM CIRCLE NUMBER(S) U1 V ❑Ncv ❑DV
yr 12
o 13-UNDER CARRIAGE 10� • 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i S i.�.,_4 COM VEH D ® U1 CO
F,,, FIRST CONTACT 1 7 • -5 •If Yes.See Sidebar C
E LG I N IL 60123 0 1 0 DZ37301 IL 2027 REAR 0 Si)
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IL D 0 3MZBPAAMOPM360837 Liberty Mutal Insurance ❑Y ®N RDEF XJ
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same A0V24322862595 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 El 11 1 06,02 l2026 06 29 ®pm AM in a Work Zone? NJ DIRP D
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1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES Check one below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 62 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
-a, ARREST NAME / / ❑PM '
o u El 12 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
45
ARRESTNAMEAM
7r 2 ❑ ❑❑PM 0 Unknown work zone type U1
, /
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1544-Solis,Yulissa 501 337-Thompson , / ❑❑PM Workers present? ®N U2 45
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
Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
1.
-<
` ` ''- -' I r INDICATE NORTH combination):or .Z-1
IN i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
L A I.- }I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or• co
L ayrrmb.nga. - 1: } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver. (C/t
for direct compensation(example:large van used for specific purpose):or
O
__ ICED _ i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
1 / —I
ICARRIER NAME Z
ADDRESS 0
I
ICITY/STATE/ZIP g
MOTOR CARR.ID El Interstate El Intrastate
Not To Scale I 0
i i i i MdeanTAva. 0--- -- Not in Comm./Govt. 0 Not in Comm./Other
0
-"--------1 - USDOT NO. ILCC NO. C
XI
Source of above z
. If Yes,Name on placard O
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?
❑ 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
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE