HomeMy WebLinkAbout2026-00038201 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II UHI UU II III 1111OOH 111111I1OO
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00428:612
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INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 12]5501-$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 202612026-00038201 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 06 30 2026 E�IAM ❑YES ®NO U1 -<
DWIGHT ST Elgin09:23
_ _ g PRIVATE mo /day/yr ID PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FR '1T TOWED U1 Q
. LOUIS.J. 0 7 /
yr 13-UNDER CARRIAGE 1t, 12! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 m
M 2 SYTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 916-TOP S `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 6 �I y COM VEH 0 0 1 C)
N Z GENEVA IL 60134 0 1 0 FIRST CONTACT 5 7 : -� •irves.See Sidebar U1 0
EJ44327 IL 2026 REAR
TELEPHONE
IL D 0 4S4BTANC4R3228647 COUNTRY FINANCIAL ❑Y ®N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same P000132774 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ElN 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 N v ❑DV
!1 9 6 5 Hyundai Elantra 2018 00-NONE 0. Q� _1 DUE TO CRASH ❑ 2 x
0 y yr 13-UNDER CARRIAGE 10 I f: 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-.il 6 �1:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7 , .5 •If Yes.See SidebarC
Z STREAMWOOD IL 60107 0 1 CX37575 IL 2026 RE 0 Si)
M
IL D 0 5NPD84LF3JH357582 GEICO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Airlift Same 4073048458 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 0 Y U2 Z
N 1 ® 11 1 61 ,01 ,026 09 23 ®❑PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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o� 2 0 2 15 ) ! ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME QUETEL, LOUIS,J. 11-904-B 456-447(w) / ! ❑PM
1 ® 1 1 1 0 CITATIONS ISSUED PENDING • UtilitySLMT
oN SECTION CITATION NO. ROAD CLEARANCE TIME 0
_ AM u, 35
t 2 0 ARREST NAME 61 +01 ,026 09 50 [�PM 0 Unknown work zone type
x T
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 35
456-Romalo,Carmine 401 - , , ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
A I �� 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } } transporting employees in the course of their employment(example:employee X
l- transporter-usually a van type vehicle or passenger car):or w
L -----}----; ".. s$ - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
- —�rttt!il for tlireccompensatron(example:lare van used for specific purpose):or Q
__ _ } } } L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
r r -1- 1 1 II r , Not To Scale 1 - ADDRESS O
V)
I CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
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
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
Gray White
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE