HomeMy WebLinkAbout2026-00058180 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00058180 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
N RANDALL RD El in03:16
® ❑ RELATED ❑Y ®N 09 24 2026 12,— ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION ITl
•
0 !MI N E S W West Highland Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
g Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
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 ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 7 /
yr 13-UNDER CARRIAGE 1U) 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 rr1
F 2 5 SYTM❑Y ®S NE El UNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;iI S 4 COM VEH 0 0 1 0
F. FIRST CONTACT 12 7 . _5 *If Yes.See Sidebar U1
Z ST CHARLES IL 60174-2636 0 1 0 S214942 IL 2027 I ,
TELEPHONE
IL D 0 1 C4HJWFG2CL196419 Country Financial ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Advanced Material Se P008215615 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O Nuv 0 i v ❑Dv
!2 0 0 8 Ford Taurus 2015 00-NONE ,�_"i Qi _, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 I I. 2 FIRE ❑ ® U2 C
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F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8i S ll, COM VEH El (El U1 CO
FIRST CONTACT 12 Y.;�"0__5 •If Yes.See Sidebar
Z Carpentersville IL 60110 B 1 0 EQ47028 IL 2027 i0
D
IL D 0 1 FAHP2E83FG111902 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Franzua. Eusebio 879905244 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
ui =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
3 3 10 / M 2 4 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 91 /41 /026 03 17 ®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 C)
2 0 28 03 91 /41 /026 03 17 ®PM ElConstruction
E
R 1 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Kampen.Alyssa.S. 11-601-Ax 366-001507 91 /41 /026 03 20 ®PM SLMT
o N 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 0 11 1 ARREST NAME 91 /41 /026 03 55 ®PM ElUnknown work zone type U1 50
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 50
366-Greer.Adam 602 11 / 31 /026 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
r r ADDITIONAL UNITS FORMS.
r ----r••--, , I I I A CMV is defined as any motor vehicle used to transport passengers or property and: >
!nip/torn/2 ; 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -'- -' I El r INDICATE NORTH combination):or p0
,—
r BY ARROW 2 Is used or designed to transport more than 15 C
g sp passengers including the driver
i ImpeG7g1 - r r r (example:shuttle or charter bus):or 0
; ; ; I c =i
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- I- --I--•--I (11111 - } i- } transporting employees In the course of their employment(example:employee X
L ----------; I rL
- I. 1 transporter Is nosed or d usually designated to transpicle or ort between 9 and 15 pC
assengers,ssen rs,including the dryer,
Not To Scale } } } for direct compensation(example:large van used for specific purpose):or 0
L L____a____.I _ t i i. , 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires 'D
rn
J placarding(example:placards will be displayed on the vehicle). ;p
W7HIghland7Ave. CARRIER NAME Z
ADDRESS 0
T.
N.7Rarrdell7Rd. - CITY/STATE/ZIP g
I I MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __. I I
I USDOT NO. ILCC NO. m
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 M
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE