HomeMy WebLinkAbout2026-00004169 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III HH II11II UH UU I IlU III ifi HH11IHH000000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0041119 0
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q 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 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00004169 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
925 ST CHARLES ST Elgin 08:23
® ❑ RELATED ❑Y ®N 01 21 2026 ❑AM YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 3 Cl)
❑ FT/MI N E S W 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
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
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Mannan,Alif, M. BMW M3 2010 00-NONE ,, • 12 a:/
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NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
to l •!!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 rr1
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,i, 6 I,.4 COM VEH 0 Ea 1 C)
Z West Chicago IL 60185 0 1 0 EX68792 IL 2026 FIRST CONTACT 7 07 _;REAR
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TELEPHONE
IL D 0 WBAWC7C56AE271101 Progressive ❑v IglN U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Same 866374979 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
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N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 mlv 0 Ixv 0 Dv CIRCLE NUMBER(S) U1
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN O `0istraetlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s- 1. 6 j(,4 COM VEH D ® U1 CO
FIRST CONTACT Jr 7�'—_,SOS •byes,See Sidebar
ELGIN IL 60120 0 1 0 FM99426 IL 2026REAR
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IL D 0 SFNRL5H94CB070234 Accurate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Romo Gutierrez, Baltazar 12-2493341-00 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOE) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(,(A.DDRESS)/(TELEPHONE! (EMS) (HOSPITAL)
1 3 06 / F 2 4 0 1 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 01 /21 /2026 08 23 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 3 28 99
! / ❑PM• ❑Construction
1
Z3 ❑ 'xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
oEl 11 1 ARREST NAME Mannan,Alif. M. 11-601 1551000302 / / El PM SLMT
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0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
r 2 ❑ ARREST NAME AM
7 / / pM ❑Unknown work zone type 30
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2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1551-Dede,Joseph 401 02 , 10/2026 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.
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 truck trailer -<
r__--; 4111 combination)or —IINDICATE NORTH -1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC
- } (example:shuttle or charter bus):or
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
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Not TO Scale I } } . transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
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L L.___a__...I. - 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
I HI } } } for direct compensation(example:large van used for specific purpose):or �
L L____a____. L L L L L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). m
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CARRIER NAME Z
ADDRESS 'n
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51
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'"' CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
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Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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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
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE