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HomeMy WebLinkAbout2026-00052501 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 4 Sheets 01111101111 I0110 II I 111110111001110000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X+ 61197 u, 1 U2 1 1 1 U116 U2 1 U, 1 U2 U, 1 u2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202612026-00052501 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED PRIVATE 0 Y ®N 08 29 2026 12,— ❑YES ®NO U1 -< MICHIGAN AVE Elgin mo /day/yr 10:59 ®PM FLOW CONDITION m _ 15COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ® ®!MI N OE s w Lake St WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER p PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) 1 1 FOR DAMAGEDAREA(S) FRONT TOWED U1 I� Jeep(after 198�1 rokee 2017 00-NONE , 12 , OUE TO CRASH ® ❑ / yr F © 13-UNDER CARRIAGE 9 I I! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 1 r<rl M I 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i;�6 �i__s *Ir yes.See sidabar Ut COM VEH 0 Ea 1 0 ZFIRST CONTACT 11 7_ELGIN IL 60120 0 1 0 GG85223 IL TELEPHONE NA 0 1 C4PJ MAB7HW569830 NIA ❑Y 0 N U2 I''I in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same NIA 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 0 0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 Dv CIRCLE NUMBER(S) U1 yr 13-UNDER CARRIAGE tQ;l t2 2 FIRE ❑ ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 0 a 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN O `0istraction Value POINT OF 8 I 4 U1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH 0 ® CO I.* FIRST CONTACT 5 Y��_,'�Os •IfYes,See Sidebar C 3578427B IL 2026 I 0 fp M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 GCRDAEK6PZ227243 Ace American Insurance Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = EMKAY INC TRUST ISA H11367689 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 08 r 29 r2026 10 59 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 E 2 0 28 99 / r 0 PM• ❑Construction 1 Z34 3 0 Ixi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o 1 ® 11 1 ARREST NAME Choc Coy. Margarito 11-601-Ax S1547000247 r r El PM SLMT • I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility o N DI AM 25 r 2 0 ARREST NAME Choc Coy. Margarito 3-707 S1547000248 r r PM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1547-Steele.Justin 1o1 341-Cox 10 r 06 r2026 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••--, , 1 A CMV is defined as any motor vehicle used to transport passengers or property and: Z �____r____; f � �] combinationporra gmore thanpounds(example:truck ortruckrtrarler -I 1. tin 10,000 INDICATE NORTH p1 i I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or C) 3. Is designed to carry15 or fewer passengers and operated a contract carrier O } } } transporting employee In the course of their employment(example:employee MLdirD��4Ave transporter-usually a van type vehicle or passenger car):or CO L 4. Is used or designated to transport between 9 and 15 passengers,including C }--- ----; UMl2 - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or .D L L____a____. IM L L I t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires��. m -- placarding(example:placards will be displayed on the vehicle). ;p rUnit 1 -- -1 CARRIER NAME Z ADDRESS 0 C) CITY/STATE/ZIP 1 ii ii i. i. .i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other --- --1 USDOT NO. ILCC NO. m x Source of above z . • m 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 ❑ No 0 Unknown g D Did Carrier Safety Regulations(MCS)violation contribute to the crash? A ❑ Yes I 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 VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 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 Silver White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE