HomeMy WebLinkAbout2026-00056951 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00056951 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED PRIVATE ❑Y ®N 09 18 2026 ❑AM ❑YES ®NO U1 —<
N RANDALL RD Elgin mo /day/yr 08:05 ®PM FLOW CONDITION Ill
10(� COUNTY PROPERTY El ® N DOORING El #OF MOTOR ❑SLOW 15 '
® 1C.'r MI N E O Vtr 19O WITH VEHICLES INVLD ❑ STOPPED U2 -I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ®Y ElN PEDALCYCLIST 123 N ® FREE FLOW # LNS 0
(g)DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
yr 13-UNDER CARRIAGE i FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OD. 2
9 9 SYSTEM IN O ENGAGED 0 15-OTHER p9 16-TOP 3 DISTRACTED ❑ ]$1 U2 2 =
❑Y ON DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
6 4
'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I_6 1i,_ COM VEH 0 j$J
10 1
I— 0 9 0 FIRST CONTACT 7 : _5 *IrYes.See Sidebar Ut 0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
none ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same none 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 99 G0)
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV
2 O O O Nissan Rogue 2016 00-NONE i1_"1 t2..-_, DUE TO CRASH ❑ 2 73
0r 13-UNDER CARRIAGE 10'I 2 FIRE 0 El U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOPO3 * X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistraci on Value 9 0
POINT OF 8 i1 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5�,:_
FIRST CONTACT 3 7 _,-_5 •• •If Yes.See Sidebar
— Loves Park IL 61111 0 1 0 FR72690 IL 2026 aR 0 C
D
IL D 0 5N1AT2MV7GC861080 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3840884SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 0 Y U2 Z
N 1 ® 11 1 09,18 i2026 08 06 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 20 06
N 3 0 CITATIONS ISSUED 0 PENDING + / ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 4
—a, ARREST NAME / / ❑PM '
1 ® 1 1 1 UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
r 2 El ARREST NAME 091 18 12026 08 06 ®PM El Unknown work zone type U1 0 AM 45
n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
❑Y
2 2 3 0 ❑AM Workers present?D.
366-Greer.Adam 900 337-Thompson , , 0 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 truckrtrailer -<
i- I r I combination):or —I
` ' ' I r INDICATE NORTH p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
I I I - (example:shuttle or charter bus):or
Ir 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
-----I-----; I I I - . I- . transportingemployees in the course of their employment
enger
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i. <.__-a_ ...I. I I I. 1 transporter4. sed or deli nated to transehrt betweeicle or n 9 a d c5)(example:
ptrs,irtclrrdmg the driver,
N au7da } } • for direct compensation(example:large van used for specific purpose):or 0
L L____a____. I I I - t i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
_ I
I I placarding(example:placards will be displayed on the vehicle). M
erterr,>caeonsNmm_ ` CARRIER NAME
� � ' 1p - - - - ADDRESS
0
D
r 0 � I I I
CITY/STATE/ZIP 0
Not To Scafe_� I I I - MOTOR CARR.ID 0 Interstate El Intrastate
I r 0 Not in Comm./Govt. 0 Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
XI
Source of above z
. 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 g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II ❑No 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Red
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE