HomeMy WebLinkAbout2026-00046833 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 II 1111111111111111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004329733
u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119
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 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 2026I 2026-00046833 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED PRIVATE ®Y ❑N 08 04 2026 ❑AM ❑YES ®NO U1 -<
SHANNON PKWY 1 W ROUTE 20 Elgin mo /day/yr 05:37 ®PM FLOW CONDITION m
®15 ®!MI N E OS Vtr SHANNON PKWY I W ROUTE 20 COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW 15 Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
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 0 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Levenhagen. Faith.C. 1 1
yr . Q
13-UNDER CARRIAGE �0 i ' 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 0 m
F 2 SYTM IN ENGAGEis-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i� S �i COM VEH El El 1 0
~ Saint Charles I L 60175 0 1 0 FIRST CONTACT 1 7 . -_5 *lI Yes.See Sidebar U1
Z EW45674 IL 2027 ' E
TELEPHONE
IL D 0 3FA6PORUOKR241125 Auto Club Insurance Assoc ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Levenhagen.Aaron AUT701510254 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r
RESPONDER D
Refused ❑Y El 2 ou
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES 0
1 9 6 7 Mitsubishi Outlander 2017 00-NONE 111
1�I•
t2 c,_2 FIRE DUE O CRASH 0 ® U2 2 C
o mo 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN O *Distract n Value 0
POINT OF 8 it l"4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5
FIRST CONTACT 4 7 ,_OS •If Yes,See Sidebar
Z Gilberts IL 60136 B 1 0 AK81430 IL 2027 I 0
IL D 0 JA4AZ3A30HZ051388 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 1974807-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman 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 ❑Y U2 Z
U 1 ® 11 1 08/04 ,2026 05 37 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 2 99 08,04 ,2026 05 50 ®PM ❑Construction >F
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ❑AM ❑Maintenance U2
oD ® 11 1 ARREST NAME Levenhagen. Faith.C. 11-901-A 489000575 08,04 i2026 05 58 Igi pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
r 2 ❑ ARREST NAME 08 i 04 ,2026 06 44 ®PM El Unknown work zone type U1 50
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
489-Reyncllds.Allison 900 393-Gutierrez 09 , 15,2026 09 00 ❑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
- } (example:shuttle or charter bus):or
® , 3. Is designed tocarry 15 or fewer passengers and operated by a contract carrier I O
`----' ---•' es pa g pe
I. } } transporting employees in the course of their employment(example:employee
Nor lb scare transporter-usually a van type vehicle or passenger car):or w
' ,. 4. Is used or designated to transport between 9 and 15 passengers,including (,)
} } } g po passen rs,includi the driver,
ij[ L
rsre.n.no for direct compensation(example:large van used for specific purpose):or
__ __ - _ t l. I. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
` placarding(example:placards will be displayed on the vehicle). XI
7 —I
CARRIER NAME Z
ADDRESS
ir 6s9nou s730 D
w
CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
'r ; _Y____1 - USDOT NO. ILCC NO. rn
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'; ❑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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Black
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE