HomeMy WebLinkAbout2026-00002661 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets IIIIII 11 IIII
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202612026-00002661 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 01 14 2026 ®AM ❑YES ®NO U1 —<
PRESTON AVE Elgin09:49
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W SUMMIT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 4 /
yr Chevrolet Malibu 2010 00-NONE
Q Q -
DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SY5 ❑Y ONM❑UNK VEH. O AT CRASH IN O 15-OTHER
99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i COM VEH 0 j$J 1 0
ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1
Z DX28124 IL 2026 REAR
TELEPHONE
IL D 1 G 1 ZE5EB7AF138237 United Equitable ❑Y ®N U2 13 , m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ILU024078 4 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
m t{ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 IIIAV 0 KKv 0 Dv CIRCLE NUMBER(S) U1
1 9 6 4 Honda Odyssey 2006 00-NONE O QI-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1:,-4 COM VEH ❑ ® U1 CO
HREAR
FIRST CONTACT 12 7�_,_.5 •(ryes.See Sidebar
ELGIN
IL D 5FNRL38766B422897 Magnum Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same I LP2827557 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 4 01 ,14 /2026 09 49 ®❑pM 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 C)
o"
2 ❑ 11 12 ) ) ❑PM, ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Cartagena Deras.Jose.G. 11-1204-B W3400165 r r El PM SLMT
o N
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME [3 Utility
30
F 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 30
340-Phillips. Kathryn 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
-I- 0 - combing r more than pound (example:truck or truck/trailer 1. Has a weight rating10 000 5 i -<
INDICATE NORTH tion)o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_Not To Stela I - (example:shuttle or charter bus):or 0
3. Is designed tocarry15 or fewer passengers and operated a contract carrier O
I- I- --I-_._.� I y } } } transporting employee in the course of their employment(example:employee
�,,
{ transporter-usually a van type vehicle or passenger car):or w
L L.___a____� �, n° 1. } } } •4. Is used or designated to transport between9and15passengers,includingthedriver. y
_ _ _ _ ,,= _ - - - I I I for direct compensation(example:large van used for specific purpose):or
L L____a____.I .4'f':.`_l i - t i. I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
D
? CARRIER NAME Z
ADDRESS 0
T.
C)
1 —Car i. CITY/STATE/ZIP
CARR.I ElEl5
_ i. i. i. 4. MOTOR ARR. D Interstate Intrastate g
I I T I ❑ 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 0
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 iO No 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
Red Gray
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE