HomeMy WebLinkAbout2026-00036314 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111 0110 ll 11111 101 0 0
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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 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00036314 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'l
W HIGHLAND AVE Elgin 08:58
® ❑ RELATED ®Y 0 N 06 22 2026 DAM ❑YES ®NO U1 -<
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FTlMI N E S W WING PARK BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q$3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
NAME(LAST,FIRST.M) Ko.Gunill mo 0 8 / /2 0 0 1 Honda Civic 2024 00-NONE „_ OI_1 DUE TOCRASH ❑ EN
13-UNDER CARRIAGE 10 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SYTHER
5 ❑Y ON UNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 is-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI S 4 COM VEH 0 Ea 1 0
F.
Bartlett I L 60103 C 1 0 FIRST CONTACT 12 7 ; _--5 *If Yes.See Sidebar U1
Z ES90148 IL 2026 E
TELEPHONE
IL D 2HGFE2F5XRH582595 Progressive El IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 866462654 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑NIAV 0 KKv ❑DV
!1 9 6 8 Toyota Prius 2015 00-NONE O," 12..-_, DUE TO CRASH 0 2 x
0 13-UNDER CARRIAGE o E FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraceon Value 9 0
POINT OF 8 i COM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:L- C
FIRST CONTACT 11 7 _-5 *(ryes.See Sidebar
— Crystal Lake IL 60014 0 1 0 809-AC45 IL 2026 I 0 Si)
IL D JTDKN3DU9F1882295 First Chicago Insurance C ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same ILS1338550-00 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)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 61 /21 /026 09 36 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 2 99 61 /21 /026 09 36 mi PM ❑Construction *
R 3 0 ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
-a, ARREST NAME Ko.Gunill 11-1204-B S1552000377 61 /21 /026 09 01 ®PM SLMT
® 11 1 0 • Utility
o N 1 SECTION CITATION NO. ROAD CLEARANCE TIME Ely CITATIONS ISSUED PENDING
0 AM
t 2 ElARREST NAME 61 /21 /026 08 58 ®PM ❑Unknown work zone type U1 30
2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AZ Workers present? ❑Y 30
1552-Thompson.Ahmad Rashad 601 71 Ill ,026 01 30 ®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 -<
` ` -'- ' Mo».nneiw r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
I _ } (example:shuttle or charter bus):or C
X
< <-----;-•-•; �� - transportingdgo lin the course of 5 or fewer he r emplrs oyment example:employee
a contract ner
t F employeesemployment
transporter-usually a van type vehicle or passenger car):or CO
L L____a____-I 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } } for direct compensation(example:large van used for cific ur mdudi the driver,
Pe ( P 9 specific purpose):or 0
' L____a____. - - uNH rF. - < < . 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
I ; il t III
71. placarding(example:placards will be displayed on the vehicle). XI
M
. '
N"°'A9° CARRIER NAME
1
I Z 7.
ADDRESS 'n
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0
rn
Not To Scale CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
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 ❑ 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
to
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
Black Gray
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