HomeMy WebLinkAbout2026-00046187 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II� III HH II11I1 1UHI
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X( 26169*
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q 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 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00046187 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
ST CHARLES ST El In 02:47
® ❑ RELATED ❑Y ®N 08 01 2026 DAM YES ®NO U1 -<
_ _ g PRIVATE mo 1 day 1 yr ®PM FLOW CONDITION m
FT!MI N E S W WATCH ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Egl 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 NIA/ 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
NAME(LAST,FIRST,M) Mendala. Brian.G. mo 0 4 /
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 SYTM IN ENGAGE❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_IL 6 I,.4 COM VEH 0 E! 1 O
H 1- BARTLETT I L 60103 0 1 0 FIRST CONTACT 12 7_. _-s *II Yes.See Sidebar U1
Z G F12802 I L 2027
TELEPHONE
IL D 0 JHMCM563X3C018863 Travelers ❑Y IlN U2 1—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6171347302032 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑mAv 0 NOV ❑Dv
0 0 5 Toyota Camry 2022 00-NONE 11"i t2 -_, DUE TO CRASH ❑ 2
0 Yr 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF T CONTACT 6 Y..II.Mi-__5 C•IOf Ms geeSidebarH ❑ ® U1 CO
H ELGIN IL 60120 0 1 0 DC54939 IL 2027REAR C
M
IL D 0 4T1 K31 AK6N U032727 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3409731-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (0081 (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 0 Y U2 Z
N 1 ® 11 1 8) ,J2 /26 01 47 ®pm AM in a Work Zone? ®N DIRP D
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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 .,
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2 ❑ 28 18 + I 0 PM• ElConstruction *
Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
o1 ® 11 1 ARREST NAME Mendala. Brian.G. 11-601 S1570-000237 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
El AM
r 2 El ARREST NAME 8) r)2 126 02 47 ®PM El Unknown work zone type U1 3O
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ❑AM Workers present? ❑Y 30
1570-Tomlin. Eli 400 320-Cox , / ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; ; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is
L L.___A_. 1 ..._... . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or c0
< <.__-a-_-_- , l• < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:__ ; t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 0
co
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
.----4-----4 ,--- -Y- ; ; , ;
USDOT NO. ILCC NO. m
73
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
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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
White Red
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE