HomeMy WebLinkAbout2026-00053814 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XOD4377884
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INVESTIGATING AGENCY DAMAGE TO ANY ❑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 ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00053814 VENT
ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
RT20 RELATED ❑Y ®N 09 04 2026 03:50 ❑AM ❑YES El NO U1 -<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
0100/MI N O S W rt20JWest Nesler Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
0 9 /
yr 13-UNDER CARRIAGE ) 2 , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 3 1<T1
M 2 SY4 ❑Y ®SNEM❑UNK VEH. O AT CRASH IN O 15-OTHER
99-UNKNOWN 9 76•TOP 3 *Distraction Value 1 ALGN •2
•
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s :il 4_5 *If Yes.See Sidebar U1 COM VEH 0 gJ 1 0
F. FIRST CONTACT 12 7_ _,_
Z Asbury IA 52002 0 1 0 PTM343 IA 2026 Is
TELEPHONE
IA C 0 1 FMCU9G D9J U B44019 Encova ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 5000618517 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ® N 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0
yr Ford Edge 2012 00-NONE 00i.O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 1. 2 FIRE 0 El U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S ..,_4 COM VEH 0 ® CO
FIRST CONTACT 6 Y__{_O ._5 ••(ryes.See Sidebar
~ 60110 0 1 0 GE16444 IL 2027 REAR O CC/)
M
IL 0 2FMDK4JC3CBA60977 Statefarm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3738915-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (WI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
3 5 01 /
D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 09,04 /2026 03 50 ®pm AM in a Work Zone? NJN 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
o"
2 0 28 99 + / 0 PM• ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Haugen.Jackson.T. 11-601-Ax 1563-240 / / El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 El ARREST NAME 09/04 /2026 04 40 0 PM El Unknown work zone type U1 5O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50
1563-Rodriguez.Carlos 801 10 /20/2026 01 30 ®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 -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ - } (example:shuttle or charter bus):or 0
N Not 7o seals J 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
L. -A---•-I
- I. } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
i_ i. __}----; wairvaa - I. } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
„�e,—u_+_r� _wka �r_.ra— for direct compensation(example:large van used for specific purpose):or O
III
<____A____;
i rlE -)1, "e. -�3: _ i. . i. 5. Is any vehicle used to transport any hazardous material(HAZMAT) m
. placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
' ADDRESS
I
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
I. -- . ... - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
Tan Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
Arties . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE