HomeMy WebLinkAbout2026-00034555 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI U� I� liii
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004272.26
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00034555 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 fl
WALNUT AVE El09:14
® ❑ RELATED ®Y ❑N 06 15 2026 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION MFT!MI N E S W WILCOXAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 99 Cl)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NOV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
/ / FOR DAMAGEDAREA(S) FROto TOWED U1 Q
Unknown.0. Unknown Unknown 00-NONE 11 . 12 DUE TOCRASH ❑ VI E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE iE
101 2 FIRE El
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 2 <
9 9 Y El N ®UNK VEH. AT SYSTEM IN 9
❑ ENGAGEDCRASH 9 15-OTHER
99-UNKNOWN 9 16.TOP 3 0 _
`Distraction Value 9 ALGN
s 4 COM VEH 0 j$J
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[s !i,_ 1 0
~ 0 9 0 FIRST CONTACT 1 7_; _5 *IIYes.SeeSidebar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR M
1 47 1 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
❑ DRIVER 0 PARKED 0 DRIVERLESS N PED 0 PEDAL 0 EWES 0 NMV 0 KV 0 DV CIRCLE NUMBER(S) U1
/2 0 0 5 Unknown Unknown 00-NONE 11_"j 12 -_t DUE TO CRASH ❑ ❑ 99 xi
0 Yr 13-UNDER CARRIAGE 10'1 2 FIRE ❑ ❑ U2 C
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M 9 9 ❑Y ❑N El UNK VEH. AT CRASH 99-UNKNOWN `OistractonValue 9 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM ❑ El
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FIRST CONTACT 00 7�REARS •IfYes.VEH See Sidebar C
H ELGIN Z IL 60123 0 9 0
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IL D 0 Not Applicable ❑Y ❑N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 47 1 Not Applicable SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph RESPOND N 1 u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
W 06 /
U2 0 Z
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
N 1 ® 12 1 06/15 /2026 09 14 0 AM 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 18 99 06,15 /2026 09 21 PM
® • El Construction
*
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
—a, ARREST NAME 06/15/2026 09 23 ®pM '
S' N ® 12 1 ❑ •CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
t 2 ARREST NAME AM
7 ! / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1568 Baer.Amkar 700 ! / ❑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 -<
c ` --I -' • INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i (example:shuttle or charter bus):or 0
L A N 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 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____.l VAat° Avo J } 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } for direct com nation exam I lar a van used for s cific ur o ):or the driver,
Pe ( P 9 Pe p pose):or O
L L--_-a-___.I — — —p•03- - 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
—I
CARRIER NAME Z
ADDRESS 0
T.
0
CITY/STATE/ZIP g
i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
USDOT NO. ILCC NO.
Not To Scale ! 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 M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE