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HomeMy WebLinkAbout2026-00050871 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII II II I fl11 IH ll fl 0100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004353056 u, 1 U2 2 4 1 U, 4 U2 U, 1 U2 U199 U2 5 6 U1 3 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202612026-00050871 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ® ❑ RELATED 0 Y ®N 08 22 2026 DAM ❑YES ®NO U1 -< SHALES PKWY Elgin 11:36 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT N E S W BODE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGED AREA(S) FRO4T TOWED U1 O Phongmany.Orion.A. 1 1 / yr 13-UNDER CARRIAGE ©1 2 FIRE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ]$I U2 M M 2 4 SY❑Y ®Nn 15-OTHER SE❑UNK VEH. ATCRASHM IN n ENGAGED 99-UNKNOWN 016 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,ii 6 I'.4 COM VEH ❑ j$J 1 0 ~ ELGIN IL 60120 0 1 0 FIRST CONTACT 9 t _; __5 *II Yes.see Sidebar U1 0 Z 4385956B IL 2027 REAR TELEPHONE IL D 0 1 FTER4LR4TLE01390 Geico ❑Y ®N U2 ni 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m ro Elgin Fire 1 99 9 Same 6261120387 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 ou ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row yr 12 _ 71 o 13-UNDER CARRIAGE 10.i :., FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 4 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 1._5 CIOMs gee SidebarH 0 C CO F` REAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < RESP❑YDNDER❑N U1 = (UNIT! (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 1 4 1 2 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 1 3 08/22 /2026 11 36 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 en t 2 ❑ 43 15 18 08!22 /2026 11 36 ®PM ❑Construction R O 0 ]$j CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a ARREST NAME Phongmany.Orion.A. 11-601 1553000422 08/22/2026 11 41 ®PM SLMT o ❑u1 CITATIONS ISSUED PENDING Utility SECTION CITATION NO. ROAD CLEARANCE TIME o N 0• AM 30 t 2 ElARREST NAME 08/23 /2026 00 32 M PM ElUnknown work zone type U, n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 1553-Jentsch.Clarissa 202 09 /22/2026 09 00 0 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-_--4. - ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C � _, N _ (example:shuttle or charter bus):or n . Not To Scale I r 3. Is designed to carry 15 or fewer passengers and operated 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 CO L L.___a___.. �j 7 I. } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. N } for direct compensation(exam :large van used for speific purose):or O ' L.._-a____. t i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M placarding(example:placards will be displayed on the vehicle). XI m "'- CARRIER NAME Z _e 1-41° - __ ADDRESS 'n n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. _Arties/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE