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HomeMy WebLinkAbout2026-00004013 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UH U� �� I11 III ifi^HH1 fl11DD000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 111926 u, 1 U2 3 4 3 U116 u2 U, 1 u2 U, 1 U2 5 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$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 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202612026-00004013 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ®Y 0 N 01 21 2026 ®AM ❑YES IX]NO U1 -< N RANDALL RD 1 190 Elgin mo /day/yr 03:07 ❑PM FLOW CONDITION m On ®!MI N E S © randall rd1 1 90 COUNTY PROPERTY :I'COUNTY ® N DOORING ❑y #OF MOTOR ElSLOW Cl) Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD El STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 2 / yr 13-UNDER CARRIAGE 16 2 FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m F 2 5 ❑Y ®N SYSTEM VEH. AT CRASH 99-UNKNOWN 9t6•TOP 3 `Distraction Value ALGN = • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 'i.4 COM VEH 0 E! 1 0 Z ELGIN IL 60124 0 1 0 CM85684 IL FIRST CONTACT 12 7_;REAR __s ves.See Sidebar Ut TELEPHONE IL D 0 1 N4AL2AP3CC239103 Allstate ❑Y ®N U2 r ni .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 99 9 Valdes Zepeda. Rafael 811 810 135 3 m `o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV yr 12 _ 71 o 13-UNDER CARRIAGE 10 1 c. 2 FIRE ❑ ❑ U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac) n Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7 6 ,-L-5 CIO e1s.EH See Sidebar ❑ C CO F` REAR` C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YDNDER❑N U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 29 1 H&H Electric Company 2 traffic control devices 01 ,21 ,2026 03 07 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 10 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ;, t 2 ❑ 2830 COMMERCE ST Franklin IP6rk 60131 28 11 r ! ❑PM ❑Construction * R 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME Valdes.Cassandra.A. 11-601-Ax 1548000182 t ! ❑PM SLMT o u 1 ❑ B!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility t 2 ❑ ARREST NAME Valdes.Cassandra.A. 11-407-A 1548000181 01)21 l2026 05 30 In PM ❑Unknown work zone type U1 45 n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑y 1548-Crandall. Matthew 502 03 ,03,2026 01 30 ®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 I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- }--__r-_--; } INDICATE NORTH combination):or —I Abf TO Saab I P1 r� BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or imoataioiwial L A 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier 0 } } } transporting employees In the course of their employment(example:employee 73 ® y transporter-usually a van type vehicle or passenger car):or w `.___A iM v 4. Is used ordesinatedtotrans rtbetween9and15 passengers,including rCjt } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L i... __;- ' l 3 l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m - --- placarding(example:placards will be displayed on the vehicle). XI -1 1� CARRIER NAME Z ADDRESS 0 V) ? n CITY/STATE/ZIP C) MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z . xi Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 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? 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White 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_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BYlT6 DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE