HomeMy WebLinkAbout2026-00032697 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 101111111 IIIl 1111110
1111110 11U
1111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00426 624
u, 9 U21 1 1 1 U, 9 U2 1 U199 1_12 1 U199 U2 1 1 9 U123 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00032697 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
419 DUNDEE AVE El 05:12
® ❑ RELATED ❑Y ®N 06 07 2026 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C)
! ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 00 r n<
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
F 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN $ 4 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iII 6 i COM VEH 0 Ea 1 C)
I- 0 9 0 FIRST CONTACT 6 ca:L.Q;_-5 *I(Yes.See Sidebar U1 0
c Z REAR
E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
NIA ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same NIA 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uv 0 NCv 0 DV CIRCLE NUMBER(S) U1
!1 9 yr 2 Ford Fiesta 2011 Do-NONE 1�__' 12...®DUE TO CRASH ❑ C 2 73
Ti 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C
M 9 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes,See SidebarC
~ ELGIN Z IL 60120 0 1 0 GD99358 IL 2026 REAR 0
M
IL D 0 3FADP4FJ4BM100791 Kemper ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 12RA000101954 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
/ 00 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 4 06,07 l2026 05 12 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 30 15
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
-a, ARREST NAME / / ❑PM '
1 ® 11 4UtilitySLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME 0
❑CITATIONS ISSUED PENDING
0 AM
t 2 ElARREST NAME 06 t 07 12026 05 12 ®PM ElUnknown work zone type U1 10
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1561-Saroyic• Mirko 102 393-Gutierrez , / ❑❑PM Workers present? ®N U2 10
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
Not To Scale N
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
i- }____r____; ,::: } combination):or -<
-`'t• ., y;._.y _ INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} } ,• (example:shuttle or charter bus):or
to
7 r r 3. Is designed tocarry 5 fewer passengers and operated a contract carrier 0
eS 1 or
-- •- i.d.71 - } } } transport) em to ees In the course of their em
Ett
ng p y pbymar).or ample:employee w f transporter-usuallya vantypevehicleorpassengercar):or �4. Is used or desi nated to trans rt between 9 and 15 ge ng rCjt
!' 4l } } g po passen rs,includi [he driver, XI
for direct compensation(example:large van used for specific purpose):or O
L L____a____. L 5. Is anyvehdeusedtotransportan hazardous materal(HAZMAT)thatrequires m+ _'y� placarding(example:placards will be displayed on the vehicle).
21.
I
I - CARRIER NAMEZ
ADDRESS ')
rnI CITt'/STATFJZIPn
Ii. i. i. i. 4. CMOTOR CARR.ID Interstate Intrastate I Hlcko,p?PL I USDOT NO ° Not in Comm.lGaA.NO Not in Comm./Other 0
ILCC m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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
Black Green
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE