HomeMy WebLinkAbout2026-00033011 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil 11111111111 DIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X4262615
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00033011 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ®Y 0 N 06 09 2026 ®AM ❑YES ®NO U1 -<
NORTH ST Elgin10:29
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W COLLEGE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NIAV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 7 !
yr
Chevrolet Camaro 2010 00-NONE DUE TO CRASH ❑ EN
1 i, 12 0E
13-UNDER CARRIAGE FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 0•
m
M 2 SY 15-OTHER
4 ❑Y ®SNE El UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL B ii,4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar U1
Z EN85102 IL 2026 REAR
M TELEPHONE
IL D 0 2G1 FC1 EV6A9207374 Insurfance Navy ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same ILA 007041 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 3 0
m CIRCLE NUMBER(S) U1
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES O IOAV ❑NCv ❑DV
'1 9 9 4 Jeep(after 196g)ind Cherokee 2014 00-NONE 0.. Qj-_, DUE TO CRASH 0 2 x
0 y yr 13-UNDER CARRIAGE 10 I Ic 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y NJ N ElUNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 .lid.._ 4 COM VEH D ® U1 CO
F„ FIRST CONTACT 11 7 -5 C.
If Yes.See Sidebar C
ELGIN IL 60123 0 1 0 EW57232 IL 926 REAR 0 N
IL D 0 1 C4RJFBG4EC568677 Farmers Insurance ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 542245589 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 06,09 l2026 10 39 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 X
0 2 ❑ 28 23 , / ❑PM ❑Construction *
Z 3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Banner. Marcus. E. 11-601 254001608 / ! El PM SLMT
o N 1
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
H 30
T 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type -1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
254-Henke. Robert 301 331-Ziegler 07 , 14/2026 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` `-- ''- -' 0
r INDICATE NORTH combination):or -<
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
'lam•
_ } (example:shuttle or charter bus):or
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L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__._.l udtt anal t 4. Is used ordesi natedtotrans rtbetween9and15 ssen rs,includingthedriver,
F for direct compensation(exam :large van used for specific purpose):or 0
L -a-___.: otner Parked Unt :. < < 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
•u
S I placarding(example:placards will be displayed on the vehicle). XIN D
_. CARRIER NAME Z
i.
ADDRESS 0
V)
C)
r CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate El Intrastate 5
Not To Scale I '
I I T c0
)❑ Not in Comm./Govt. Not in Comm./Other
i- --- --1 USDOT NO. ILCC NO. m
XI
Source of above 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
'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
Red Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE