HomeMy WebLinkAbout2026-00050778 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mill III H IIIl
10111 0 1111DDMM 1111111 IDD 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X8564
u, 1 u21 3 4 1 U199 U299 u,99 u2 1 u,99 U2 1 1 2 u, 1 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00050778 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 mCONGDON AVE El03:52
® ❑ RELATED ®Y 0 N 08 22 2026 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W N LIBERTY ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
0 DRIVER ❑ PARSED 0 DRIVERLESS 0 PED 21 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONr TOWED U1 Q
NAME(LAST,FIRST,M) mo yr
Unknown. Unknown / ! Unknown Unknown 2025 00-NONE „ 12 , DUE TOCRASH ❑ EN
13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
5 3 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN 2
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1[6 !i,_ 1 0
I— 0 1 FIRST CONTACT 99 7_; _5 *II yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
K6F0002480 None ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 1 None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
> O PO®N XI
m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 N6V 0 DV
!1 9 9 9
^ NAME(LAST,FIRST,M) Williams.Vasaan.C. Dodge Avenger 2014 00-NONE 111 12 �i DUE 2 FIRE O CRASH 0 ® U2 C 2
o Yr 13-UNDER CARRIAGE (,
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9116•TOP 3 X
❑Y EQ N ❑UNK VEH. AT CRASH 99-UNKNOWN • •Distraction Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S- L 6 11:,-4 COM VEH D ® U1 CO
FIRST CONTACT 99 7�. __.5 •If Yes.See Sidebar
m ELGIN IL 60120 0 1 0 EY28235 IL I C
9 Cl)
IL 0 1 C3CDZAG 1 EN226371 None ❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same None BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
U1 1 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 ® 13 1 08/22 l2026 03 52 ®AM in a Work Zone? ®N 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 C)
o"
2 18 99 ( ( 0 PM• ❑Construction *
7
Z 3 0 ]$g CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o 1 ® 13 1 ARREST NAME Williams.Vasaan.C. 3-707 1530000850 / ! El PM SLMT
I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
8 N AM 15
r 2 0 ARREST NAME Williams.Vasaan.C. 3-708 1530000851 ( / ❑❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 981 10 (06/2026 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 truckrtrailer -<
i- }---.r----; } combination):or —I
/ INDICATE NORTH p1
//I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C' n ; (example:shuttle or charter bus):orI "b*ro 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
I ' - } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
I ri t I. 4. Is used or designated to transport between 9 and 15 passengers,including (Cj)
i. }-----}----; - } } } g po passen rs,includi the driver,
Unft for direct compensation(example:large van used for specific purpose):or 0
L L i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). m
0
Unit 1 D
CARRIER NAME Z
/// I/f
ADDRESS
! C
r r -1- 1 / I + 4.
CITY/STATE/ZIP 0
r g
I - i. i. i. i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ 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 VIM 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
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE