Loading...
HomeMy WebLinkAbout2026-00059080 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 0110 II I flfl I 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 04391:45 u, 1 U21 2 4 1 U1 8 U2 1 U, 1 1_12 1 U, 1 U2 1 5 10 U1 3 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00059080 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 BETHPAGE CIR Elgin07:28 ® ❑ RELATED ®Y 0 N 09 28 2026 12,— ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W DORAL DR COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 TOWED U1 FOR DAMAGEDAREA(S) FROM TOWED 0 1 / yr q 13-UNDER CARRIAGE ©' 12 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 0 0 U2 0 m F 2 4 ❑Y ®SNEM❑LINK VEH. 0 AT CRASH IN ENGAGE0 99-UUNKNOWN 016-TOP 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Dail 6 �'.4 COM VEH 0 j$J 1 0 m F. ELGIN I N I L 60124 0 1 0 FIRST CONTACT 11 7 : --5 *II Yes.See Sidebar U1 Z EN17538 IL 2027 E TELEPHONE IL D 0 3G NAXU EGORS208020 Erie Insurance El ®N U2 19 , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Q021115239 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y El 2 0 p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ !2 0 0 2 FR ^ NAME(LAST,FIRST,M) Shepard. Kyle.S. Ford Fusion 2017 00-NONE 0. Qi'-_1 DUE TO CRASH ❑ 2 x o Yr 13-UNDER CARRIAGE 10( ) 2 FIRE ❑ El U2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 11:, COM VEH D ® U1 CO FIRST CONTACT 11 7� 5 •(ryes.See Sidebar F- . ELGIN Z IL 60124 0 1 0 FL46377 IL 2027 I 0 M IL D 0 3FA6P0H79HR370789 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 3705233SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 4 09(28 l2026 07 29 ®PM AM in a Work Zone? ®N DIRP > co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � o" 2 ❑ 20 28 1 ( ❑PM ❑Construction * 1 Z3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 oEl 11 1 ARREST NAME Sciacca. Kathleen. M. 11-601-Ax 366-1509 / ! El PM SLMT o N • 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 0 AM t 2 El ARREST NAME 09(28 l2026 07 29 ®PM El Unknown work zone type U1 25 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25 366-Greer.Adam 800 11 (03(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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI 21. --I CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 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 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m 11 TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White Silver 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