HomeMy WebLinkAbout2026-00035829 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
III 11 IIIIII UHI U I� III I Hill 11111 0111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004276772'
u, 9 u21 1 1 1 u, 2 U2 1 U1 99 1_12 1 U,99 U2 99 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A 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 ®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00035829 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
315 S WESTON AVE EIIn10:30
® ❑ RELATED ❑Y ®N 06 20 2026 ®AM ❑YES El NO U1 —<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FRONr TOWED U1 Q
Unknown,O. Unknown Unknown 00-NONE „ 12 , DUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.Top 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ;iL 6 1�.4 COM VEH El El 1 0
I• 99 FIRST CONTACT 7_ —, 5__ C.
II Yes,See Sidebar U1
0 9 0 UNKNOWN REAR
2 Z
_ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Unknown. Unknown Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
L O YO23 N 0
0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KQV 0 Dv
yr Hyundai Santa Fe 2010' Do-NONE ,t-1 12..-_, DUE TO CRASH ❑ 21 2 x
o 13-UNDER CARRIAGE 10 1
9 16•TOP 3 2 FIRE ❑ El U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR n
0 0
SYSTEM IN ENGAGED 15-OTHER 9
a ❑Y El D UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value(
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1I6 �L_'4 COM VEH D ® U1 CO
FIRST CONTACT 6 Y__{_O ._ If Yes.See Sidebar 5 •
H DL35426 IL 2027 REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5NMSHDAG5AH395394 Allstate ❑Y J N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Olsen. Phillip, M. 932511532 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
m
##occs y
71
/ / U1 1 D
/ / 0
EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 06,20 /2026 05 30 0 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
2 ❑ 18 18
N 1 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ID PM
S' N El 1 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility25
SLMT
r 2 ❑ ARREST NAME AM
, , ❑❑
7 PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 565-Villagomez• Mireya 701 337-Thompson , / 0 PM Workers present? ®N U2 25
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.
.. .. 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 -<
I. combination):or 1
INDICATE NORTH -1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
-:. I C-D _ } (example:shuttle or charter bus):or
X
I- I- --I—•--; I W� transporting employeened to s inthe course 5 or fewer passengers
their emaployment nd operated
xample:employee
transporter} r }
transporter-usually a van type vehicle or passenger car):or X
L L.___a._ Ave 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y
I. } } for direct compensation(example::large van used for speific purpoe):or
the driver,
L L--_-a-___. I� - t i i I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
O
'D
placarding(example:placards will be displayed on the vehicle). XI
I —I
CARRIER NAME Z
ADDRESS 0
O
CITY/STATE/ZIPg
- i. i. i. i. 4. MOTOR CARR.ID 0 Interstate El Intrastate
rr Not J o Scale I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
--- --1 - USDOT NO. ILCC NO. m
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?
❑ 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 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE