HomeMy WebLinkAbout2026-00036170 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110
II III I�IIIIII IIIIIIIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0D4278,031
u, 1 U21 2 4 1 U1 2 U2 1 u, 1 U2 9 u,99 U2 1 1 2 u, 3 U2 1 *P 011`j
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00036170 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
BOWES RD Elgin
® ❑ RELATED ®Y 0 N 06 22 202612,— ❑YES N NO U1
PRIVATE mo /day/yr 12:42 NPM FLOW CONDITION m
�O�F /MI NOS W South Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 16
Kane HIT&RUN ❑Y N N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 5 /
Lincoln Town Car 2006 OD-NONE ,1,. OPtf i_, DUE TOCRASH ElEN
13-UNDER CARRIAGE 10 ' 2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED N 0 U2 0 171
M 2 4 ❑Y ®N SYSTEM
❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 6 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�6 4 COM VEH 0 Ea 1 0
" �- SOUTH ELGIN I L 60177 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.See Sidebar U1
ZLFDL-EN IL 2026 REAR
TELEPHONE
IL D 1 LN H M83W06Y600576 Pekin Insurance ❑v N N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 006055724 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED '}�. PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
/2 0 0 6 Huffy 00-NONE ,�_O' t2 "_, DUE TO CRASH ❑ N 2
Ti 13-UNDER CARRIAGE ( 2 FIRE ❑ ® U2 C
F 5 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NiN ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractlonValue 6 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH El U1 CO
FIRST CONTACT 10 7� -.5 •IfYes.See Sidebar C
n ELGINREAR0 Si)
n Z IL 60120 B 3 8
n/a ❑Y 0 N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X
1 49 1 Same n/a BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U2 m
##OCCS y
71
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CD 13 1 06,22 /2026 12 43 ®pm in a Work Zone? NCI N DIRP >co
I I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
o", T
2 0 2 99 1 / ❑PM• 0 Construction X
Z 3 0 N CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
a1 ® 11 1 ARREST NAME DeLeon. Luis. F. 11-901-A 327003374W / / El PM SLMT
o N ❑CITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
I 2 ❑ ARREST NAME AM
T / / PM 0 Unknown work zone type 45
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
327 Hromadka.Scott 702 / / ❑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__--; INDICATE NORTH ,1�1 combination):or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
[...,
} (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by 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 CO
SWOON 4.1,_ } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose):or O
L i.____a____. ? C'+rr 1 _ t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires ill
placartling(example:placards will be displayed on the vehicle). ,Zmt
—1
— — — — — — CARRIER NAME Z
i _ __ ADDRESS 0
T.
I
~ I CITY/STATE/ZIP 0
Not To Scale - MOTOR CARR.ID 0 Interstate El Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other0
�I. -----"1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
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
71
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 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE