HomeMy WebLinkAbout2026-00047545 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I0110
II I OH IIH
I 011100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 33c806
u1 1 U21 1 1 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 4 11 U1 1 U2 1 .P0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 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 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 202612026-00047545 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mW HIGHLAND AVE El In11:17
® ❑ RELATED ❑Y ®N 08 07 2026 ❑AM ❑YES E)NO U1 —<
g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
_
FT!MI N E S W TRINITY ITY TER COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n
.FROM�TOWED U1 O
mo
Eveland. Ethan.G. Ford F150 2021 00-NONE 0 >2T OUETOCRASH ® CI
(LAST,FIRST,M) yr 13-UNDER CARRIAGE 16 1 I: 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 NI 2 rr1
M 2 4 SYTM❑Y OS NE❑UNK VEH. 0 AT CRASH 99-UNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, ii_6 ii.4 COM VEH 0 IE 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar Ut
iVi Z3245113B IL 2026 REAR
TELEPHONE
IL D 1 FTFW1 E54MFC45292 American Family ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 410974019580 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER •
RESPONDER >
Refused 0 Y ® N 2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row ❑Ncv 0 Dv
!1 9 y 2 Toyota Camry 2014 00-NONE 10' t2 (,-2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
ii
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac( n Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 6 t 4 COM VEH 0 ® U1 CO
FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.SeeSidebar C
ELGIN IL 60120 B 1 0 FH93612 IL 2026 • i 0 Si)
Z
IL D 4T1 BF1 FK1 EU304536 Farmers ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 544796887 SAC • E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP .20 G
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 06 /
71
/ / UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 81 /12 /26 11 17 ®PM AM in a Work Zone? NJN DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 • �
en
2 0 17 03 81 ,12 /26 11 23 ®PM ❑Construction
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
o 1 ® 11 1 ARREST NAME Eveland. Ethan.G. 11-601-Ax 753554 81 /12 /26 11 30 ®• PM• El Utility SLMT
j$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0
o N AM 40
r 2 El ARREST NAME Eveland. Ethan.G. 11-503-A 753553 / / pM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 40
1558-Lundvick.John 602 91 , 81 /026 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 -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I ® - } (example:shuttle or charter bus):or X
Not To Scale
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
I 4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} } for direct com nation exam I lar a van used for s cifi ur o ):or the driver,
Pe ( P 9 Pe p pose):or O
i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a / ` placarding(example:placards will be displayed on the vehicle). XICARRIER NAME Z
unrr r -- — — _ 1 ADDRESS
0
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
--'-- ----1 - USDOT NO. ILCC NO. rn
Xi
Source of above 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE