HomeMy WebLinkAbout2026-00055583 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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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 2
VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00055583 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
W HIGHLAND AVE Elgin 07:39
® ❑ RELATED ®Y 0 N 09 12 2026 12,— ❑YES ®NO U1 -<
_ _ PRIVATE mo /day/yr NPM FLOW CONDITION m
FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR ID SLOW 1 (/)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 4 /
yr 13-UNDER CARRIAGE 10l ! 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 4 (<Tl
M 2 6 SYM IN ENGAGED 15-OTHER
❑Y ®N EE❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $• iI 6 jl COM VEH 0 0 1 C)
~ ELGIN I L 60123 B 1 0 FIRST CONTACT 5 7 :RFAR-O •II Yes.See Sidebar U1 0
Z FM11802 IL 2027
TELEPHONE
IL D 2LMDJ8JK7BBJ14995 Elephant Insurance ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 214-000-197-06 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 0
N DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 row 0 iv ❑Dv CIRCLE NUMBER(S) U1
'1 9 6 7 Subaru Impreza 2026 00-NONE ,�_"i Qr O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 N U2 C
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M 2 9 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6-TOP 3 X
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH 0 N U1 CO
FIRST CONTACT I Y _, _6 •(ryes,See Sidebar
= ELGINREAR
IL D J F1 G U HJC5T8223642 State Farm ❑Y N N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 3497041-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
3 6 04 /
, D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 09,12 /2026 07 39 ®AM 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 11 1 2 99 09,12 /2026 07 41 pM
® • El Construction
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cn
R O 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
oER 11 1 ARREST NAME Casey.Christian. P. 11-901-A 1549-535 09/12/2026 07 44 igi pM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
AM
T 2 0 ARREST NAME 09/1 2 /2026 08 21 ®PM 0 Unknown work zone type U1 30
2 2 3 ID ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1549-Brown. Bryan 601 10 , 14,2026 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 -<
INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r r r (example:shuttle or charter bus):or C
I x� I 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
i J I 1 I is - } r } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; 4
1, - } } } •4. Is used or designated to transport between 9 and 15 assen passengers,including the driver. C
i_6+, l�` for direct compensation(example:large van used fors cific purpose):or
__ _ i. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires 'D
i im
`J XIplacarding(example:placards will be displayed on the vehicle).
--
I
CARRIER NAME Z
_ ADDRESS 0
V)
N78tab?St ()
Not To Scale Ti I 1 I CITY/SraTF�R.IZIP C
r I Ii. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
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
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 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 White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE