HomeMy WebLinkAbout2026-00049407 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00049407 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �l
® ❑ RELATED PRIVATE ®Y 0 N 08 16 2026 12,—AM ❑YES ®NO U1 -<
KI M BALL ST Elgin mo /day/yr 01.37 ®PM FLOW CONDITION M
0100 /MI N E S ® Dundee Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
0 2 /
yr 13-UNDER CARRIAGE IE
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
F 2 SYTM 4 ❑Y ®S NE❑UNK VEH. O AT CRASH 0 99-UNK 15- NOWN THER9 76•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il_6 ii 4 COM VEH 0 E! 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar Ut
Z3863576B IL 2027 REAR
TELEPHONE
IL D 0 SFPYK3F41 SB000352 Stonegate Insurance ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILSP0017852 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER •
RESPONDER D
Refused 0 V El 2 ou
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
/1 9 yf 2 Buick Lacrosse 2014 00-NONE 10 1 t2 (,-2 FIRE DUE El
CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•Tt9P 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraetlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'ij- 6 IL.4 COM VEH ❑ ® U1 CO
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FIRST CONTACT 8 O7 ;J__,�-5 *IfYes,See Sidebar
ELGIN IL 60120 0 1 0 DH28216 IL 2027 • I 0 Si)
IL 0 1G4GB5G38EF238779 American Property&Casua ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same PAIL00026017 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
16 05 /
/ / UI 3 D:A
/ / 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 81 /61 /026 01 37 ®PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP H .
AM U1
0
2 0 28 20 / / ❑PM ❑Construction
" 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
o 1 ® 11 1 ARREST NAME Bernal Duran. Martha 11-601 S1542-000994 / / El PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility
o r 2 0 ARREST NAME Bernal Duran. Martha 11-709-A W1542-000995 81 /61 /026 01 37 ®PM El Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®A-
M Workers present? ❑Y 30
1542 Chafe. Ethan 101 91 , 51 /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 truckrtrailer -<
H,'H.
tir / O ! comWrtatbn)orN INDICATE NORTHBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
/ / _ i ,. (example:shuttle or charter bus):or
_Nat TL Scglo r r 0
/ / 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
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} } } transporting employees In the course of their employment� (example:employee � X
j/4 / transporter-usually a van type vehicle or passenger car):or lP
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< <-__ ----, c.."^-%c:,+ - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or O
L s i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i
placarding(example:placards will be displayed on the vehicle). ;p
-tH,yt 1 - -- -1
Y�� CARRIER NAME
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3 _ __ ADDRESS
/ t CITY/STATE/ZIP g
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! - MOTOR CARR.ID ❑ Interstate ❑ Intrastate1 1 T 1 / ❑ Not in Comm./Govt. Not in Comm./Other°
;I. --- _- _ USDOT NO. ILCC NO. rn
m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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' -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 Tan
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE