HomeMy WebLinkAbout2026-00058916 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III HH II11II UHI U� I� 11111111O 11111IUUU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X+ 91 75
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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 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00058916 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 —n
CONGDON AVE Elgin
® ❑ RELATED ❑Y ®N 09 28 2026 ®AM ❑YES ®NO U1
PRIVATE mo /day/yr 07:27 ❑PM FLOW CONDITION ITT
02040,M1 NOS W North Dundee St COUNTY PROPERTY El'COUNTY ® N DOORING ❑y #OF MOTOR ElSLOW 4 Cl)
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
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
/ / FOR DAMAGEDAREA(S) FROM TOWED U1 O
Unknown.O. Unknown Unknown 00-NONE 11_
12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 3 <<T1
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N DUNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
a 4
'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i�a �i,_ COM VEH ❑ )gJ 1
I.. FIRST
9 0 FIRST CONTACT 99 7_; _5 *lI sees.See Sidebar U1 0
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
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D Y°N0DER N X
m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 KCV 0 Dv
/1 9day yr 0 M Ford Transit Connect 2017 oo-NONE ,�_"j t2 -_, DUE TO CRASH ❑ (gl 773
0 13-UNDER CARRIAGE 10'I i 2 FIRE 0 ® U2 73
F 2 4 ❑Y N ❑UNK VEH. AT CRASH 99-UNKNOWN Distractionvalue
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & 4 COM VEH El El U1 CO
FIRST CONTACT 7 OS 7 _, _5 •If Yes.See Sidebar
Elgin IL 60123 0 1 0 543737D IL I C
0 cn
Z D
0 1 FDCR5PM2HKA91180 Trumbull Ins Co ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Premier IL Elgin Eas 84UENCCONA4 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPOND
Y°N❑DN U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL)
2 7 12 /
. DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
N 1 ® 11 9 co
09/28 /2026 07 27 ®❑PM AM in a Work Zone? ®N DIRP D
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 28 20
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a ARREST NAME / / ❑PM '
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
,
30
r 2 ❑ ARREST NAME AM
1 / ❑❑PM ❑Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
254 Henke. Robert 200 , / ❑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 -<
c ` --I -' I. INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
---------- I I - transporting rting mployeened to slIn the course passengers5 or fewer hir mplooynd ment example:employeener X
i i I11 ® } F I. transporter-usually a van type vehicle or passenger car):or
i. `-----;----i j
i I I •,,,,,,,�,,,, - } } } 4. Is used or designated to transport between 9 and 15 passengers,including[he driver, y
,� l for direct compensation(example:large van used for specific purpose):or
igfp •p
< .I. s .�: _ } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires-- ————— placarding(example:placards will be displayed on the vehicle). D
L L 1 r n I rr ... - -- ME —I
I {h.rwrws. CARRIER NA Z
'�'I ` — 7° '-� _ ADDRESS 0
CITY/STATE/ZIP I n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® No 0 Unknown
T.
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?
❑ Yes II No ElUnknown A
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 ®No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White
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/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE