HomeMy WebLinkAbout2026-00037769 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011111111001110111111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XOD4287486
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00037769 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
® ❑ RELATED ❑Y ®N 06 28 2026 ❑AM ❑YES ®
PRIVATE NO U1
RT20 EB Elgin mo /day/yr 01:05 ®PM FLOW CONDITION m
50 ® O COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR El SLOW 15 u)
!MI N S W rt20 eb WITH VEHICLES INVLD IN STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J Y ElN PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<r1
SYSTEM IN ENGAGED 15-OTHER 9 16.TOR 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 $ i iL a i�.4 COM VEH 0 )gl 1 0
P. FIRST CONTACT 99 7_ -, _5_ *IIYes.See Sidebar U1
0 9 0 UNKNOWN REAR
2 Z
M TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 lii
nla ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same nla 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 99
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMV 0 NCv 0 DV CIRCLE NUMBER(S) U1
1 yr 9 6 9 Chevrolet Trail Blazer 2024 00-NONE 'o,� t2 (,-2 FIRE DUE o CRASH ❑❑ U2 2 C o 13-UNDER CARRIAGE
Ti
F 2 4 ElElEl ,6 Y N UNK VEH. AT CRASH 99-UNKNOWN (Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Olen Y 4 COM VEH ❑ 0 U1 W
FIRST CONTACT 7 7 __Li.__5 •IfYes.See Sidebar
— Bloomingdale IL 60108 0 1 0 EQ69364 IL 2027 • 'AR 0
IL D KL79MPSLXRB079834 Progressive ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 994557528 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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CO 11 9 06,28 /2026 02 10 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
Fic 2 ❑ 20 18
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ) ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 8
-a ARREST NAME / / El PM '
o, N 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
30
r 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
565-Villagomez• Mireya 701 - , / ❑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
SS ADDITIONAL UNITS FORMS.
r ----r••--, , ! ^ A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�R^ 1. Has a weight rating more than 10,000 pounds(example:truck or truck(railer -<
i- }-- -'-- --' I N r INDICATE NORTH combination):or
d BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} } } transporting employee In the course�of their empbym�ent(example:employee � �
� transporter-usually a van type vehicle or passenger car):or co
L ----------; ``- - I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
for direct compensation(example:large van used for specific purpose):or O
L L.._-a____. l. I 1 t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
F ? Q! placarding(example:placards will be isplayed on the vehicle). XI
m
1 —..� .+
ff / CARRIER NAME Z
111 / ADDRESS 'n
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C)
CITY/STATE/ZIP 0
r - i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 I ❑ Not in Comm./Govt. 0 Not in Comm./Other O
----Y__--; l! Not To Scale ( - ILCC NO O USDOT NO. m
XI
Source of above z
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'; 0 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
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/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE