HomeMy WebLinkAbout2026-00053301 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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II 111111110001100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X361183
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00053301 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
® ❑ RELATED ®Y 0 N 09 02 2026 ®AM ❑YES ®NO U1
LAWRENCE AVE Elgin10:58
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W N ALDI N E ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROf4r TOWED U1 Q
Mora.Saul 0 3 /
yr 13-UNDER CARRIAGE 10.I !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 0 m
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it 6 ii,4 COM VEH 0 Ea 1 0
m ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_; -__5 *9Yes.See Sidebar U1
Z 159606F IL 2027 REAR
TELEPHONE
IL D 1 GBJC34U67E170486 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0003037 sfo 13 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 24 (,�j
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv
!1 9 y 4 7 Honda HR-V 2027 00-NONE O QI-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 El U2 C
c
M 2 5 ❑Y ❑SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑N UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7�. 5 •If Yes.See Sidebar
I- ELGIN 1 EAR
M I L 60123 B 1 0 FZ20867 I L 2027
IL D 3CZRZ2H51 VM701718 State Farm ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 0146970-sfp-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 El 11 1 09,02 l2026 10 59 ®❑PM in a Work Zone? NJ DIRP co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
Si T
2 ❑ 2 99 + ! ❑PM, ❑Construction *
7
Z 3 ❑ xi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Mora.Saul 11-901-A 327003448 ! ! El PM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
1 2 ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type U1
El
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
327-Hromadka.Scott 601 09 ,26,2026 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 truck trailer -<
i- }__-_r_-_-; } combination):or
INDICATE NORTH 51
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Q'N�, _ (example:shuttle or charter bus):or C
< <---- -•-•; I transporti3. Is ng employeened to sl5 or fewer in the course passengers
rhea emand ployment operated
xample:employeener X
} } }
__ L— transporter-usually a van type vehicle or passenger car):or c0
L i.-----}----; i 1 - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
It g for direct compensation(example:large van used for specific purpose):or
.
____a____. "A101A.et— —u-."1 _ L 5. Is any vehicle used to transport hazardous material(HAZMAT)thatrequires m
placarding(example:placards will be anyisplayed on the vehicle). ;p
. 1
- CARRIER NAME Z
ADDRESS
CA
Not To Scale I CITY/STATE/ZIP o
MOTOR CARR.ID 0 Interstate 0 Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- -'4 USDOT NO. ILCC NO. m
XI
Source of above z
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 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 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
Red Black
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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE