HomeMy WebLinkAbout2026-00033731 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 ❑$501-$1.500 ❑ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00033731 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
SHALES PKWY El12:00
® ❑ RELATED ❑Y ®N 06 12 2026 ❑AM D YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W E GH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 15 u)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
0 6 !
Ford Explorer 2017 00-NONE 11_ Oi-1 DUE TO CRASH ❑
13-UNDER CARRIAGE 10 ' 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
F 2 SY 15-OTHER
4 ❑Y ONM DUNK VEH. 0 AT CRASH IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL 6 4 COM VEH ❑ Ea 1 0
~ ELGIN N I L 60120 0 1 FIRST CONTACT 12 7_: _5 *Irves.See Sidebar U1
Z FQ51770 IL 2026 REAR
TELEPHONE
IL 0 1 FM5K8F85HGB51958 Geico ❑Y igi N U2 13 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6255716331 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 2 0
m g DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑ uv 0 NOV ❑DV CIRCLE NUMBER(S) U1
!1 9 9 6 Hyundai Kona 2020' 00-NONE 1t"i 12..-_1 DUETO CRASH ❑ C 2
...
— 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C
P.
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistraclIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII 6 .. .4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 ••(ryes,See Sidebar
Z SOUTH ELG I N IL 60177 0 1 EP54697 IL 2020 FIRST
C
M
IL D 0 KM8K3CA53LU514316 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 864328312 BAC
$
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)
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 1 06,12 /2026 03 40 0 pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
Fsi 2 0 28 99
N 3 0 0 CITATIONS ISSUED CI PENDING + 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
30
r 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ — ❑AM Workers present? 0 Y 30
1515-BellEck.Stacy 302 / / ❑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
A 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- ;.---.;-----; N - ( combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L Not To Scale I _ i. e. r ,. (example:shuttle or charter bus):or 0
L A — } 3. Is designed to carry 15 or fewer passen ers and o rated 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 w
L L.___a__... •* - 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
I _ I Etalonsahat I } } } for direct compensation(example:large van used for specific purpose):or 0
L L--_-a-___. 'l ` - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—1
1 CARRIER NAME Z
._ ADDRESS 0
th
C)
CITY/STATE/ZIP g
3 MOTOR CARR.ID 0 Interstate ❑ Intrastate
T ~ 1 ii ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
Y I
USDOT NO. ILCC NO. C
m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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? 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
White 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