HomeMy WebLinkAbout2026-00032231 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00426G880
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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 ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00032231 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mBODE RD El In01:44
® ❑ RELATED ' V 0 N 06 05 2026 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W SHALES PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (/)❑ Cook HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 --I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NIA/ 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
0 8 /
yr 11. 12
13-UNDER CARRIAGE 101 2 FIRE VI IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
M 2 4 ❑Y ®SNEM Dn is-OTHER
UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i 4 COM VEH El Ea 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar U1
Z 2787521B IL 2027 Ismi
TELEPHONE
IL D 1 GC4YPEY9LF109530 STATE FARM ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2403265 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 0
p;rg- DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 Dv
!1 9 5 3 Mazda CX5 2018 00-NONE 0. Qi•-0 DUE TO CRASH 0 ❑ 2 x
0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
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F 2 5SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7� .5 •(ryes.See Sidebar
= ELGIN IL 60120 0 1 0 Y544545 IL 2026 aR 0
IL D JM3KFBCM2J0465552 STATE FARM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 2700111-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
KNIT) (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 06/05 /2026 01 44 ®pm in a Work Zone? ®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
cii 2 18 18 06/05 /2026 01 44 PM
1 ® • ❑Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
ARREST NAME 06/05/2026 01 50 ®PM
1 ® 11 4 0CITATIONS ISSUED ❑PENDING UtilitySLMT
o u2. SECTION CITATION NO. ROAD CLEARANCE TIME • El
t 2 El ARREST NAME 06/06 /2026 02 06 ®PM El Unknown work zone type U1 0 AM 35
n IX 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1517-Le Cates, Brittany 401 331-Ziegler / / ❑❑pM Workers present? ®N U2 35
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 -<
c ` --I -' r INDICATE NORTH combination):or -I
0
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
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; I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
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} } } transporting employee In the course of their employment(example:employee
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N 4alsuorter-sedord�llnatedtotrans vehicle
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for direct compensation(example:large van used for specific purpose):or
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L L.___a. — — • r_>. - i L 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires
., placarding(example:placards will be displayed on the vehicle). XI
11 ' CARRIER NAME Z
I ADDRESS O
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Not To Scale I ! 1- CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ElIntrastate -
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
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Source of above z
. IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No =
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Silver Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE