HomeMy WebLinkAbout2026-00057074 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 Mil II II I flfl h11111101E1
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00057074 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
® ❑ RELATED PRIVATE ❑Y ®N 09 19 2026 ❑AM ❑YES ®NO U1
ANN ST Elgin mo /day/yr 02:06 ®PM FLOW CONDITION M_
� COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 15 u)
I295 ®!MI N O S W Brook St WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER p PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 9 /
yr
Ford Transit Connect 2024 00-NONE + DUE TO CRASH ❑ EN
++- +2 -
13-UNDERCARRIAGE +al 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 1 I<T1
M 2 SY15-OTHER
4 ❑Y ®SNE UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 +6•TOP 3 ,Distraction Value 9 ALGN x
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $• i� a �I COM VEH 0 Ea 1 n
~ Hanover Park I L 60133 0 1 0 FIRST CONTACT 5 7 : R-O •IrYes.See Sidebar U1 0
Z 4E20410 IL ' E
TELEPHONE
IL D 0 1 FTBW9CK3RKA60462 Tort Ely igi N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 USPS Tort 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
22 (,0j
p DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr Jeep(after 196�)npass 2019 00-NONE OI t2 ! 2 DUE TO CRASH ® U2 73
C
2
o _ 13-UNDER CARRIAGE
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O' DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0 X
a 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
POINT OF 8 it -4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ���', COM VEH ❑ ® CO
FIRST CONTACT 11 7- -5 •If Yes,See Sidebar
~ D120-IS IL 2026 RE 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3C4NJCBBOKT820054 State Farm ❑V ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
99 9 AYALA. ELIZABETH 3509498SFP13 BAC
$
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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
E/ MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 18 1 09,19 /2026 02 06 ®PM in a Work Zone? ®N DIRP co
1 NI PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 0 03 99 / / ❑PM ❑Construction *
3
R 3 0 $I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Christiansen.Thomas. P. 11-601-Ax W1528-000415 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
0 AM
t 2 El ARREST NAME 09 r 19 12026 02 30 0 PM El Unknown work zone type U1 25
x T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
1528 Rivera. Kevin 102 , , ❑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- A Combination):or
` ' ' r INDICATE NORTH p1
[.. N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or C)
L A 3. Is desgned tol carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee
�+er transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } • •
for direct compensation(example:large van used for specificpurpose):or [he driver,
1 Pe ( P 9 Pe or
mum •OD
— - l. I I 5. Is an vehicle used to transport an hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
nauuw,s CARRIER NAME Z
ADDRESS 0
C)
CITY/STATE/ZIP g
Not To Scale I - i. i. i. MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; 0 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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