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HomeMy WebLinkAbout2026-00047312 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III H IIII IIIIII U II IOU III OHIO DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X+ 29572 u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 u, 1 U2 1 3 15 u, 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 202612026-00047312 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m1425 N RANDALL RD El® ❑ RELATED ®Y ❑N 08 06 2026 07:19 12,— ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑ N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES ❑uuv ❑!Cy 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGED AREA(S) FRO TOWED U1 O Bos ue.Areli 1 2 / yr 13-UNDER CARRIAGE ©,I ,. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m F 2 8 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i 4 COM VEH 0 ZgJ 1 0 ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *II yes.See Sidebar U1 Z BY79831 IL 2027 REAR TELEPHONE IL D 0 1 G KKN KLA8KZ199196 Progressive ❑Y Il N U2 1- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Jamies.Juventino 865858582 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused El El 2 ou g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv !1 9 8 9 Honda CRV 2026 00-NONE 11_. 12 "_, DUE TO CRASH 0 ❑ 2 0 13-UNDER CARRIAGE o I 2 FIRE 0 ® U2 C c ® F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'i'.!,_4 COM VEH ❑ ® U1 W FIRST CONTACT 9 7 _,__5 •• •UYes.See Sidebar C Z Galena IL 61036 B 1 0 FH95884 IL 2027aR 0 Si) Z IL D 0 7FARS4H72TE000635 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 999413394 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Sherman RESPONDER u1 = (UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 01 / 2 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 81 /12 !26 07 19 ®PM AM in a Work Zone? ®N DIRP D co 1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 0 2 28 81 r 12 /26 07 20 PM ® • ❑Construction >E Z 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 -a ARREST NAME 81 /12 /26 07 25 Igi PM ' , o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 25 F 2 ARREST NAME AM T / / ❑❑PM ❑Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 25 489-Reynolds.Allison 500 / / ❑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 CI No!To � 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer ` ` ' ' I. INDICATE NORTH comWnatlon)or Le-- BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver —I -< i_ - } (example:shuttle or charter bus):or X A � one 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } 1. transporting employees in the course of their employment(example:employee X --el transporter-usually a van type vehicle or passenger car):or C L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including to } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or o :. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z ADDRESS 0 w C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other I I _I_ __I - Y 4, 1425?N?Randall?Rd USDOT NO. ILCC NO. XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m v 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 Black Blue u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . 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