HomeMy WebLinkAbout2026-00053059 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 Mil 1 II I
1E1VOl III 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X S8632
u, 9 U2 1 1 1 U1 99 U2 1 U199 1_12 U,99 U2 1 1 9 U1 99 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 7
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00053059 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
1425 N RANDALL RD EIIn08:00
® ❑ RELATED ❑Y ®N 08 28 2026 ®AM ❑YES El NO U1
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ''Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT!MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGED AREA(S) FRONT TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ID N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL s j�.4 COM VEH 0 El 1 00
I• 99 FIRST CONTACT 7_)1_ *__ II Yes.See Sidebar U1
0 9 9 UNKNOWN RE
2 Z
_ -I TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 G0)
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr Dodge Challenger 2023 00-NONE 1i_ 12._Q DUE TO CRASH ❑ 2 77
Ti 13-UNDERCARRIAGE I FIRE ID ElU2C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10. f O DISTRACTED 0 ® SPDR 0
0 0
SYSTEM IN ENGAGED 15-OTHER 9.16-TOP 3 9
a
❑Y NJ D UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value
POINT OF 8 "4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S ,._ COM VEH ❑ ® CO
FIRST CONTACT 1 Y _, _5 •If Yes.See Sidebar
H GRNVNM IL I 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2C3CDZKGOPH575175 State Farm ❑V ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Patel. Pinal. P. 1055811-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)r(TELEPHONEI (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 09/01 /2026 12 10 ®PM in a Work Zone? ®N DIRP co
1 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 0 18 18
N 3 ❑ ❑CITATIONS ISSUED ID PENDING + ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME r / IDPM
o u ER 5 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility SLMT
15
t 2 0 ARREST NAME AM
7 r r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 15
558-Lara. -izette 502 275-Engelke r r ❑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 -<
c ` --I -' r INDICATE NORTH combination):or A
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
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees in the course of their employment(example:employee P3
rter-
enger
or co
< <.___a____; I�I{41f Sii5511I x I. 42lsuosedordsignatedtotranslly a van type portbetweeicle or n9a d15rpassen rs,includingthedriver. N
} } for direct compensation(examp large van used for specific purpose):or
II'llll'IIIII'I�'II M
< a I I I } } } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle).
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IIIIII��IIIIIIIII�I� CARRIER NAME O
) ADDRESS D
rn
0
AMt Ta scam! CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"---- --1 - USDOT NO. ILCC NO. rn
PCI
Source of above z
. 0 Yes IQNo ❑ Unknown 0
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
LOCAL USE ONLY TRAILER VIN 2 m
O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Green
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE