HomeMy WebLinkAbout2026-00052827 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 a2 Sheets 01111101111
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II IIIIIIII II II 111111H
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 61F.39'
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00052827 VERY
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 08 31 2026 ❑AM ❑YES ®NO U1 -<
N RANDALL RD Elgin02:47
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
2 FT/vt N E S Vtr BigTimber Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
® ® O Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 5 !
yr . Q -
13-UNDER CARRIAGE 1a i 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 4 rn
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O .AT CRAM IN SH O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r 6 COM VEH 0 j$J 1_5 *If Yes.See Sidebar U1 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_:il 4 0
F. FIRST CONTACT 12 7 • _
Z Crystal Lake IL 60012 0 1 0 1 C478 FF IL 2026 I ,
TELEPHONE
IL D 0 1 G1 PE5SB8E7389103 American Heartland Insura ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Same AHQ0035097 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER •
RESPONDER >
Refused 0 Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑iiuv 0 Ncv ❑Dv CIRCLE NUMBER(S) U1
/1 9 6 6 Chevrolet Equinox 2014 00-NONE ,t"i 12--_, DUE TO CRASH 0 (� 2 73
o 13-UNDERCARRIAGE ta;I 2 FIRE ❑ ® U2 C
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M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iI 6 l',_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 Y :j_O ._5 •(ryes,See Sidebar
H ELGIN Z IL 60123 0 1 0 DX27957 IL 2027 aR
M
IL D 0 1 GNALBEK5EZ100512 Statefarm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 4116594-SFP-13 BAc • $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 81 , 11 l026 02 47 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 03 11 ) , 0 PM ❑Construction • >F
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o1El 11 1 ARREST NAME Knabusch. Patrice. M. 11-601 1560-658 , ! El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
r 2 0 ARREST NAME 81 ,11 1026 03 55 ®PM 0 Unknown work zone type U1 5O
2 2 3 ID
ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
1560-Jones. Bennett 901 10 , 61 ,026 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
jN.?Rnd8II?Rd. ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Unh -<
1. Hasa weight rating more than 10,000 pounds(example:truck or truck/trailer
c ` --I -' r INDICATE NORTH combination):or
31 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L r Unn#1 3. Is designed to carry 15 or fewer passengers and operated by 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 w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L L____a____.I t i. i i. ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
m
placarding(example:placards will be displayed on the vehicle). ;p
—1
Not To Scale i CARRIER NAME Z
ADDRESS 0
T.
Biprtmber?Rd. rn
C)
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
Y 1
I r
USDOT NO. ILCC NO. C
m
73
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. P3
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 0 No 0 Unknown M
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red 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/Owners Residence . 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