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HomeMy WebLinkAbout2026-00048988 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 Il II II0 11110111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004341940 u, 1 U21 2 4 1 u, 2 U2 1 u, 9 1_12 1 u, 1 U2 1 1 10 u, 3 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 El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 202612026-00048988 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I DAVIS RD El In11:44 ® ❑ RELATED ®Y 0 N 08 14 2026 ®AM ❑YES E)NO U1 _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m FT N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OFMOTOR 0 SLOW 1 cn ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 4 ! Toyota RAV4 2015 00-NONE ©,: Q _, DUE TOCRASH ® ❑ O 13-UNDER CARRIAGE } FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED ® 0 U2 0 m F 2 SY8 ❑Y ❑STM NE®UNK VEH. 9 AT CRASH 9 99-U 15-UNKNOWN THER O9 16•TOP 3 *Distraction Value 6 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL 6 I, 4 COM VEH 0 j a 1 0 ELGIN IL 60123 B 1 0 FIRST CONTACT 11 7 ; __5 *Il sees.See Sidebar U1 Z FW15194 IL 2026 REAR TELEPHONE IL JTMRFREV9FD133694 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 2392568SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y ❑ N 2 XI p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑!My ❑Ncv ❑Dv !2 O O 0 Honda Civic 2025 00-NONE 1("1 Qr O DUE TO CRASH 0 p 2 x oy Yr 13-UNDER CARRIAGE 16 I f. 2 FIRE 0 ® U2 C Ti M 2 5 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X ❑Y El ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI�1:,-4 COM VEH ❑ ® U1 W FIRST CONTACT 12 7�_,--- •If Yes.See Sidebar n ELGIN IL 60123 B 1 0 FB95678 IL 2026 IL D 2HGFE4F84SH319952 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Same 863108164 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPOND 0 N u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONEI (EMS) (HOSPITAL) 1 3 07 / F 2 4 B 1 0 m / / #OCCS > / / UI 2 D / / 1 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 4 81 ,41 ,026 11 44 ®❑PM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 6 C1 T o" 2 0 2 06 ! , ❑PM ❑Construction Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Stutzman,Vanessa. E. 11-902 410000843 , ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility ❑ 35 t 2 El ARREST NAME AM T 1 r ❑PM El Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35 410-DeLeon.Jessica 501 275-Engelke 9/ , 51 ,026 01 30 ®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 r1wv,.nvm 1. Hasa weight rating more than 10,000 pounds(example:truck or truck/trailer } }-- _r_ --; I } combination):or , INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or 0 3. Is designed to carry15 or fewer passengers and operated I a contract carrier O }----A--- ; N - }} } transporting employee � �In the course of their employment(example:employee X y a van type < <.___a____� _�- ` 4alsuosedordrter- estlnatedto transport betweeicle or n9 and rt5r) ssen rs,including[hedriver. C 1 } } } • for direct compensation(examp large van used for specific purpose):or 0 L____a____. } } } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires �i placarding(example:placards will be displayed on the vehicle). ,Zmt Not To Sark. I CARRIER NAME Z u,y u� - ADDRESS 0 n CITY/STATE/ZIP g I - i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other -""Y"": USDOT NO. ILCC NO. C XI Source of above Z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI 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 M D Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Red Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE