HomeMy WebLinkAbout2026-00000838 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 100111101010 fll I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X604102091
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00000838 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
N RANDALL RD Elgin05:54
® ❑ RELATED ®Y 0 N 01 05 2026 12,— ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W ROYAL BLVD COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 1 Lincoln Naviator 2006 FOR DAMAGEDAREA(S)00-NONE
FRO T TOWED U1 Q
NAME(LAST,FIRST.M) Samaniego-Munoz. Isaac mo / / yr g Q 12 1 DUE TOCRASH ❑ E
13-UNDER CARRIAGE 10 1 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY 15-OTHER
4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S �i 4 COM VEH 0 j$J 2 O
F. ELGIN N I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *llsees.See Sidebar U1
ZFS79792 IL 2026 REAR
TELEPHONE
IL D 0 5LMFU28566LJ11064 State Farm ❑v IglN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 3867301-SFP-13 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 2 0
tg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 use 0 Ncv 0 Dv
!1 9 9 8 Nissan Kicks 2020' 00-NONE 'o,1 t2 (,-2 FIRE DUE O CRASH 0 ® U2 2 C
o yr 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
POINT OF 8 i 4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5
FIRST CONTACT 5 O7 ,�=QOS •It Yes.See Sidebar C
Z Streamwood IL 60120 0 1 0 EC31565 IL 2024aR0
Z
IL D 0 3N 1 CPSCVXLL488347 Geico ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 6004040538 BAC
E
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
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 11 ,12 !26 05 54 ®FM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
1
2 ❑ 28 18 ) ! ❑PM• ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1El 11 1 ARREST NAME Samaniego-Munoz. Isaac 11-601 S1542-000632 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
t 2 0 ARREST NAME 11 )12 126 05 54 ®PM 0 Unknown work zone type U1 45
2 2 3 0 . -
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1542 Chafe. Ethan sot 21 r 71 ,026 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.
C I . A CMV is defined as any motor vehicle used to transport passengers or property and:�....Y...., D
14,ry z
141t/ 01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
combination):or
r }----i-----i Ilir. I ® ) INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
l l ' 1 Ir 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
< <.___A_._.� y I Not To Scale , - } } } transportingemployees In the course of their employment
J — g (example:employee 10
transporter-usually a van type vehicle or passenger car):or CO
L -----}----; ` I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
ti for direct compensation(example:large van used for specific purpose):or
__ - � L I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 . . . . placarding(example:placards will be displayed on the vehicle). XI
♦ —1
1_� CARRIER NAME Z
r'7.^i. :IT 0
�M - ADDRESS D
I
'` t I. '' C
I I CITY/STATE/ZIP g
_ MOTOR CARR.ID 0 Interstate 0 Intrastate
l I r l I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
Y
USDOT NO. ILCC NO. C
I I m
Source of above z
. • m
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
Tan Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE