HomeMy WebLinkAbout2026-00034946 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004276520
u1 U2 3 4 1 U1 U2 U1 U2 U1 U2 2 1 U199 U299
*P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑ssot-g1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202612026-00034946 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ®Y ❑N 06 17 2026 ®AM ❑YES ®NO U1
S CHANNING ST Elgin05:07
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION M
FT!MI N E S W VILLA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 99 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS N PED ❑PEDAL ❑EWES ❑NIAV ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
1 0 /
yr 13-UNDER CARRIAGE 10 2 FIRE 0 ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 0 M
F 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
CI N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEARI . POINT OF s ;FIRST CONTACT 15 7 ;i�S 4_5 *Il Yes,See Sidebar U1 COM VEH 0 ❑ 1
0
E LG I N IL 60123 B 1 0 2
2 Z
TELEPHONE
IL D 0 NIA ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 52 2 NIA 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER Al
RESPONDER
Provena St.Joseph ❑Y ® N 99
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❑ DRIVER ❑ PARKED ❑DRIVERLESS El PEO ❑PEDAL 0 EWES ❑NOV 0 KCV 0 DV
yr 00-NONE 'o,I t2 c,�2 FIRE DuE OCRASH 0 ❑❑ U2 99 C
o 13-UNDER CARRIAGE
c
F 1 3 SYSTEM IN ENGAGED 15-OTHER 9:1,6•TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 - 6 j1:,-4 COM VEH ❑ ❑ U1 CO
FIRST CONTACT 00 7� �.5 •If Yes.See Sidebar C
H ELGIN IL 60120 B 1 0 N
M
IL D 0 NIA ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 52 2 NIA SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER
®N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 1 61 !71 1026 05 07 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
Ei 2 2 99 61 !71 l026 05 08 PM
❑ ❑Construction
Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
®AM ❑Maintenance U2
-a ARREST NAME 61 /71 l026 05 12 ❑PM '
,
1 ® 12 1 ElUtility
0CITATIONS ISSUED PENDING SLMT
o NSECTION CITATION NO. ROAD CLEARANCE TIME
AM U1 30
T 2 0 ARREST NAME 61171 1026 05 56 0 PM 0 Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? 0 Y 30
1547-Steele.Justin 301 , r ❑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 -<
- }___-r----; combination):or
INDICATE NORTH p0
ILI) BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} A i `
I. } } transporting employee In the course of their employment� (example:employee � �
�,�„ Not To Scale I transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including CCjt
-- -- - } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or o
L L____a..... - tlining l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 0
°n°, 1 placarding(example:placards will be displayed on the vehicle). XI
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R\ _ CARRIER NAME Z
I `arms( 1 ADDRESS 0
r
)
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE