HomeMy WebLinkAbout2026-00004104 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets II 1 HH 1111 II MUH
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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/or Tow Due To Crash
0 AMENDED YR 202612026-00004104 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ®Y 0 N 01 21 2026 ❑AM YES ®NO U1 -<
N RANDALL RD Elgin 02:52
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
�90 !MI N E S W Higgins Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
I� gg 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
(i 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 n
0 2 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 <<n
F 2 SY 15-OTHER
5 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 916•TOP 3 `Distraction Value 6 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 4 COM VEH El El 1 0
F. FIRST CONTACT 12 7, ;� ,__5 *II Yes.See Sidebar U1
Z CARPENTERSVILLE IL 60110 B 1 BG52978 IL 2026 I
TELEPHONE
IL D 0 3N 1 AB7AP7GY303198 State Farm ❑Y Igl N U2 Ill . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 3411359-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Sherman 0 Y ❑ N 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 NCv 0 DV
Blazer 2023 00-NONE 1("i ,z -_, DUE TO CRASH ❑
2
0 13-UNDER CARRIAGE 10'I 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
�iI s 4 W
MI', COM VEH ❑ ®
FIRST CONTACT 6 L9_a" t.A •If Yes,See Sidebar
Lake in the Hills IL 60156 0 1 W9JWN IL 2026 izF,aR 0
IL C 0 3G N KBJ RSXPS229731 Neis Insurance Agency ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 53-897737-00 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS),)TELEPHONE) (EMS) (HOSPITAL)
2 3 12 / F 2 4 0 1
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71
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EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 01 /21 /2026 02 52 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 28 99 01,21 /2026 02 52 ®PM ❑Construction >E
R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Salazar.Janet.G. 11-601-Ax 389-5728 01,21 /2026 02 59 ®PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
t 2 El ARREST NAME 01/21 /2026 03 40 0 PM 0 Unknown work zone type U1 0 AM
45
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 45
389-Miller.Joshua 901 320-Cox 02 , 10/2026 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
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
I- 3. Is designed to car 15 or fewer passengers and operated a contract carrier O
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,� I I ` }} } transporting employees In the course of their employment(example:employee
03
L L.__.a__... transporter sed or designated nated to transy a van type ehrt betweeicle or n 9 and r 15 passengers,ssen rs,including the driver,
I } • for direct compensation(example:large van used for specific purpose):or 0
L L_._.a..... I I i. i. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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. . . . I ii .
placarding(example:placards will be displayed on the vehicle). XI
I I I CARRIER NAME —I
ADDRESS 0
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Not 7b Scale CITY/STATE/ZIP 0
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MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;...-- ----; USDOT NO. ILCC NO. rn
XI
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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White 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