HomeMy WebLinkAbout2026-00051654 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash
0 AMENDED YR 202612026-00051654 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S GROVE AVE El In03:05
® ❑ RELATED 0 Y ®N 08 26 2026 ❑AM ❑YES E)NO U1
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
15 !MI ClE S W DU a e Ct COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
® p g Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(8:DRIVER ID PARKED I]DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 0 !
yr Q
13-UNDER CARRIAGE 10 i 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m
M 2 SYTHER
4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN ENGAGED 0 99-UNKNOWN 9 1e-TOP 3 ,Distraction Value 4 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T :i1 S 4 COM VEH 0 gJ 1 0
I . ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_; __5 *Yves.See Sidebar U1
Z M220836 IL 2026
TELEPHONE
IL D 0 3FA6P0LU5KR209456 Charter Oak fire Insuranc ❑Y Igl N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
CITY OF ELGIN,City 8109160P901 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
yr Mercedes-Berg LK 350 2012 00-NONE 11_ Oj-_, DUE TO CRASH ❑ 173
0 13-UNDER CARRIAGE FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 ❑ ® SPDR n
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I ; 4 COM VEH ❑ ® U1 CO
F.... Di� _s •If Yes.See Sidebar C
BM44790 IL 2027 REAR0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
WDCGG5GB4CF748387 State Farm ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Mata,Connie 3975214SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 08/26 /2026 03 05 ®pm in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 41 99
N 3 ❑ CITATIONS ISSUED 0 PENDING + ! 0 PM- ❑Construction >E
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM
S' N ® 11 1 •
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit 25
y
SLMT
t 2 ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
482-Flentye.Jeremy uri 356-Sostre , / 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
unit3 1. Has
weightht ratingmore thanpounds(example:truck or truckrtrarler -<
-----------' I _ /� - r INDICATE NORTH tin 10,000 5"R_
f BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
aramovarave I>l�i N _ rr (example:shuttle or charter bus):or C
I ,f II 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- <.__-A-.--� I '. - y } } } transportingemployees In the course of their employment
ployment(example:employee
C
L L.___a.._.� or 73
1 III
' , 1 4alsuosedordrter- signatedtotranslly a van type portbetweeicle or n9a d15enger rpassen rs,includingthedriver,
} } • •
for direct compensation(example:large van used for specific purpose):or
L L____...... I � 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
t m
- - r placarding(example:placards will be displayed on the vehicle). 0
�1 nits , __
L Not To Scale _[ CARRIER NAME Z
I ' ' .
�. ADDRESS
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C)
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate El
l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
m
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' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/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 ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE