HomeMy WebLinkAbout2026-00046132 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI U� I� IOU III II III DUO
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00046132 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
962 DUNDEE AVE Elgin05:39
® ❑ RELATED 0 Y ®N 08 01 2026 ®AM ❑YES IX]NO U1 -<
_ _ PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT!MI N E S W Kane HIT ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
ID AT RUN 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 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) R20Nr TOWED U1 0
Lossau. D Ian.A. 0 3 /
yr 13-UNDER CARRIAGE 16) 2 , 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 5 ❑Y ❑N
SYSTEM
®UNK VEH. 9 AT CRASH D 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iL 6 I,.4 COM VEH ❑ Ea 1 0
~ Des Plaines I L 60016 0 1 0 FIRST CONTACT 12 7_; _5 *Irves.See Sidebar U1
Z FC54363 IL 2026 REAR
TELEPHONE
IL D 0 3VWC57BU7MM070988 none ®Y ❑N U2 r
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Same none 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 rg-
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV
yr 12 _ C
o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR O
El Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 9 -
POINT OF 8-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+-e COM•I sVEH See •Sidebar❑ ❑ C
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 43 1 City of Elgin tree 08/01 /2026 05 39 ®❑pM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v t 2 0 151 DOUGLAS AVE ELGIN IL 60120 11 99 ! ! ❑PM ❑Construction >F
ZJ 3 0 El CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
_<, ARREST NAME Lossau. Dylan.A. 3-707 1538000446 ! ! ❑PM SLMT
o u 1 0 igI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
o N 0 AM 30
t 2 0 ARREST NAME Lossau. Dylan.A. 11-601-A W1538000 ! ! PM Unknown work zone type U1
El
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present? ❑
1538-Estrada. Leticia 200 441-Alva ! ! ❑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 -<
c ` -'- ' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
0 - r r (example:shuttle or charter bus):or
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0
.4, Not To Scale � - I. } . transporting employees in the course of their employment(example:employee X
-- transporter-usually a van type vehicle or passenger car):or co
__ -- - t t t •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
5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
• 1 placarding(example:placards will be displayed on the vehicle). ;p
~ =1 CARRIER NAME Z
I _ _ ADDRESS O
Pw'+� T.
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;------ --. - USDOT NO. ILCC NO. m
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE