HomeMy WebLinkAbout2026-00030907 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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II III III III I 101100
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004265233
u112 u21 2 4 1 u1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U1 3 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY N OVER 51,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2026I 2026-00030907 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
N JANE DR Elgin 12:14
® ❑ RELATED ®Y 0 N 05 30 2026 12,— ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr NPM FLOW CONDITION M
FT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NOV 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRObir TOWED U1 Q
Mac Donald. Nathan.C. 0 1 /
yr 13-UNDER CARRIAGE } FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) O 2 DISTRACTED 0 0U2 4 m
M 2 8 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN THER O9 16•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL s 4 COM VEH 0 j$J 1 0
H 1- ELGIN I L 60123 K 4 0 FIRST CONTACT 10 T : _5 *IIYes.See Sidebar U1
ZDK53651 IL 2026 REAR
TELEPHONE
IL D 0 1 NXBR30E16Z609106 Unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Delgado,Antonio Unknown 1
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER r
RESPONDER
2 c
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 i v 0 Dv
1 9 8 9 Kia Motors Col portage 2025 00-NONE O-i Q!'-O DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
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M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.iI�1:,-4 COM VEH 0 N U1 CO
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
H ELGIN IL 60124 C 1 0 FM88133 IL 2026 REAR 9 N
M
IL D 0 KNDPYDDH7S7200494 Allstate ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 979667446 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER
® U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI ,(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 07 / F 9 8 C 4 0
/ / #OCCS >
71
/ / UI 2 D
/ / 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 05,30 i2026 12 15 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 2 23 05,30 ,2026 12 14 pM
® • ❑Construction >F
Z 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
- u N a ARREST NAME 05r 30/2026 12 19 ®pM '
11 4 0 Utility
0 ISSUED ❑PENDING SLMT
o,
SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM
r 2 El ARREST NAME 05/30 )2026 12 50 N PM 0 Unknown work zone type U1 35
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
449 Harris,Jacob 602 331-Ziegler / ❑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.
.- .. , CI _ A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c -' r INDICATE NORTH combination):or 23
Not To Scale i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
7 } (example:shuttle or charter bus):or
3. Is desgned to carry 15 or fewer passen ers and o rated a contract carrier O
} } } transporting employees In the course of their employment(example:employee 72
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; - } } } 4. Is used or designated to transport between 9 and 1 passen rs,including the driver,
C
J for direct compensation(example:large van used fors specific purpose):or O
L L____a____.l ^dZ .0\ - } I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m
--`i \ placarding(example:placards will be displayed on the vehicle). 23
lz
CARRIER NAME Z
__ ADDRESS 0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
T.
--- --1
i ... ' . .. .. .
C)USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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? 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
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 Maroon
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage 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