HomeMy WebLinkAbout2026-00036733 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 0110 ll 11111 101 0
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004282033
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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 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00036733 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 06 24 2026 ❑AM ❑YES ®NO U1 -<
S STATE ST Elgin mo /day/yr 0120 ®PM FLOW CONDITION m
I 0 ®!MI N E OS W National St COUNTY PROPERTY ❑Y 21N DOORING ICIy #OF MOTOR IR SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
(g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 4 /
yr 13-UNDERCARRIAGE 10l O'.-2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M I 2 SY4 ❑Y ®SNEM DUNK VEH. 0 AT CRASH IN 0 99-UNKNOWN 9 76-TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_;-iL 6 4 COM VEH 0 ZgJ 1 0
F. FIRST CONTACT 12 7_ , _5 *lives.See Sidebar U1
.... Cleavland OH 44102 0 1 0 92714Z3 IL 2025 REAR
TELEPHONE
CA C 0 1C6HJTAG9LL149496 AAA ❑y ®N U2 19 , m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same CAAS243687708 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 Mks 0
1 9 6 2 Toyota Venza 2023 00-NONE 11"j t2--_, DUETO CRASH ❑ 2 73
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl n Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6
FIRST CONTACT 6 7I- IfYes.See Sidebar 4 COM VEH ❑ ® u1 CO
• C
H Carol Stream IL 60188 0 1 0 BDV1645 IL 2027 PEAR 0
IL D 0 JTEAAAAH2PJ137372 American Family Ins ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 411375614773 BAC
E
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)1(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 r 41 )026 01 21 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 28 99 + ) 0 PM• ❑Construction *
Z 3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Gulavane.Shreyas. M. 11-601-Ax 495000500 / ! El PM SLMT
o N •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
r 2 ❑ AM
x- 7 ❑PM ❑Unknown work zone type U1
ARREST NAME 1 / ❑
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
495-Sjodir.Jacob 701 71 r 11 /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
4 1 weight rating more than 10 000 pounds(example:truck or truck trailer -<
Has a we a le:
} l N combination):or
` ''- -' Q INDICATE NORTH �
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ (example:shuttle or charter bus):or
r r r
L 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
N.swwfan..r transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
- - - -
L t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
-I
aA CARRIER NAME Z il r i. ADDRESS0
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VOW CITY/STATE/ZIP g
i I C
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Not To Scale MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
r _, ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. C
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? 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
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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
Gray White
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE