HomeMy WebLinkAbout2026-00061330 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets II I 111 IIII
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY N OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202612026-00061330 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME
HIGHLAND WOODS BLVD)ROUTE 20 ElginSECONDARY CRASH 15
® ❑ RELATED ®Y ❑N 10 08 2026 ❑AM ❑YES I NO U1 —<
PRIVATE mo /day/yr 06:46 N PM FLOW CONDITION m
I 20 ®!MI O E s w HIGHLAND WOODS BLVD I ROUTE 20 COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW 15 -I
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ICU 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 8 /
yr 13-UNDER CARRIAGE I ! FIRE ❑ N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SY n is-OTHER
5 ❑Y ®SNE❑UNK VEH. AT CRASIN n H 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, it a �i COM VEH ❑ Ea 1 0
m ~ ELGIN IL 60124 0 1 0 FIRST CONTACT 11 7_; -__S *lIYes.SeeSidebar U1
Z Q675585 IL 2027 REAR
TELEPHONE
IL D 5FNYF6H95GB096744 Progressive El ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Patel. Bharatkuma. B. 878779155 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
g DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 row 0 i v 0 Dv
1 9 8 4 Subaru Forrester 2021 00-NONE ®i Q!'-O DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10( I E FIRE ❑ ® U2 C
c
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y EIN DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
POINT OF 8 i1 A 4 COM VEH ❑ N U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .S •(ryes,See Sidebar
ZWendell NC 27591 0 1 0 LKH4327 IL 2026 I 0 C
NC D J F2SKAJC7M H507794 State Farm ❑Y ®N RDEF XJ
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Douglas. Dana. N. 4161714E0133B BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (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 ❑Y U2 Z
N 1 ® 11 1 10,08 ,2026 06 46 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 2 99 10,08 ,2026 06 46 ®PM ❑Construction *
R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ❑AM ❑Maintenance U2
—a, ARREST NAME Patel. Mahi. D. 11-901 1549-556 10,08 i2026 06 55 N PM CITATIONS ISSUED PENDING SLMT 1 ® 11 1 ❑ • Utility
oU SECTION CITATION NO. ROAD CLEARANCE TIME Ely
r 2 ❑ ARREST NAME 10 i 08 ,2026 07 39 N PM El Unknown work zone type 0 AM U1 40
2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1549-Brown. Bryan 901 11 ,09,2026 09 00 ❑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 -<
` ` '- ' Route?20 f INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or
X
— — �n _ _ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
< f- -A- -•i
} } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L .:. ..}----; IIKIIV--- - } } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
•11, for direct compensation(example:large van used for specific purpose):or o
71
L L____a..... t 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
0 rn
placarding(example:placards will be displayed on the vehicle). ;0
Not To Scale CARRIER NAME Z
, , - . i _ ADDRESS
T.
CITY/STATE/ZIP g
_ i. i. i. 4. MOTOR CARR.ID ❑ Interstate El i. Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-""Y""1 USDOT NO. ILCC NO. m
XI
Source of above z
. 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE