HomeMy WebLinkAbout2026-00001687 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 Mil it ll 1111 10111 H� �II11011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004096606
u, 1 U21 1 1 1 U, 2 U2 1 U, 1 u2 1 U, 1 u2 1 1 11 U1 1 U2 1 *P 0 1 1 9*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00001687 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED PRIVATE ❑Y ®N 01 09 2026 12,—AM ❑YES ®NO U1 -<
N RANDALL RD Elgin mo /day/yr 04:15 ®PM FLOW CONDITION Ill
05040 COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR IR SLOW 15 u)
!MI N E S W Win Haven Dr WITH VEHICLES INVLD 0 STOPPED U2 --I
ElAT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 9 /
yr 13-UNDER CARRIAGE �a) 2 : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M 2 4 SY❑Y ®SNE❑UNK VEH. O ATCRASHD15-OTHER
O 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL 6 I,.4 COM VEH 0 Ea 1 0
F.
ELGIN I L 60123 C 1 0 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar U1
Z BF36230 IL 2026 REAR
TELEPHONE
IL D 0 J F2G PABC3G8227896 Statefarm ❑Y J N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1977870-SFP-13 1 1-
15 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
1 9 9 4 Mazda MAZDAS 2013 00-NONE ,�_-1 12..-_, DUETO CRASH ❑ Ig 2
o 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac0Dn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6
FIRST CONTACT 6 71- 4 COM VEH ❑ ® U1 CO
I_5 •IfYes,See Sidebar C
Dekalb IL 60115 0 1 0 FB79086 IL 2026 PEAR 0 N
IL D 0 JM1CW2CL9D0152068 National General ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2032660711 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI j(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 6 03 /
/ / 4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 /12 /26 04 15 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 28 03 11 /12 /26 04 20 ®PM ❑Construction F
" O 0 ]$I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Wynalda. Brian.J. 11-601 W1563-000143 11 /12 /26 04 29 ®pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
r 2 El ARREST NAME 11 /12 /26 04 15 ®PM El Unknown work zone type U1 0 AM
45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1563-Rodriguez.Carlos 801 337-Thompson / / ❑❑PM Am Workers present? ®N U2 45
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
/int/.
I -<
r I 1.c Has
or more than pounds(example:truck or truck/trailer
1. Has a weight rating10 000
INDICATE NORTH tan) p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I ® } (example:shuttle or charter bus):or
r 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O
} } transportingemployeesInthecoursesoftheiremployment(example:employee 73
Not TO$C81B I transporter-usually a van type vehicle Or passenger car):OrwL L.__-a-_- I } } 4. Is used or designated to transport between9and15passengers,includingthedriver. N for direct compensation(example:large van used for specific purpose):or O
a I } } i. _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
rn
placarding(example:placards will be displayed on the vehicle). ;p
YNn?NavenlOr. - -- -I
CARRIER NAME Z
— — — — —
ADDRESS 0
D
C)1 I I CITY/STATE/ZIP
0
g
II - MOTOR CARR.ID 0 Interstate 0 Intrastate 5
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --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
co
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
Black Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE