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HomeMy WebLinkAbout2026-00002650 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 100111101010�1HH100100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004112163 u, 9 U2 1 1 3 u199 U2 U199 1_12 U,99 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00002650 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m1554 MARK AVE El In09:27 ® ❑ RELATED ❑Y ®N 01 14 2026 ®AM ❑YES ®NO U1 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m _ COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT!MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I &RUN ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED p PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRO TOWED U1 0NAME(LAST,FIRST,M) mo yr Unknown.0. ! ! f tf Unknown Unknown 00-NONE ©1 O 0 DUE TO CRASH ❑ VI E 13-UNDER CARRIAGE I FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O SYSTEM IN 9 ❑Y ❑N ❑UNK VEH. ENGAGED 15-OTHER 9 16.70P 3 DISTRACTED 0 ]$I U2 2 m 9 AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ..Ii_S Ii,_ 1 1- 0 9 FIRST CONTACT 12 7_: COM VEH 0 Ea_5 *II Yes.See&debar Ut 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 -0 UNKNOWN El Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Same UNKNOWN 3 m `o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 99 0 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv CIRCLE NUMBER(S) U1 yr 13-UNDER CARRIAGE 10 12 -2 FIRE ❑ ® U2 C Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 0 ® SPDR n ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 9 - N POINT OF (Di. 4 COM VEH CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR � I S �'_ 0 ® CO C F,,, FIRST CONTACT 7 l:!l_{_O ._5 •If Yes.See Sidebar FC71996 IL 2026 REAR 9 N M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0 1 HGFA15587L124268 American Alliance ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 10 = Sanchez Benjumea. Luis I LAA-1 085000-00 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 2 01 J 14 l2026 09 27 ®❑AM 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 ❑ 28 11 N 1 3 0 0 CITATIONS ISSUED 0 PENDING / ! ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 z —a, ARREST NAME / / ❑PM o u El 1 0 • CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 25 t 2 0 ARREST NAME AM T 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? ❑Y 25 487-Heal. Kayla 502 / / ❑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 INDICATE NORTH combination):or .Z-1 ® 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C *Ave (example:shuttle or charter bus):or 0 L L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O ---+ Mlldred4Ave - l. } } i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). m 0 �� :t D //C.` theft n CARRIER NAME Z —'^�� �er ADDRESS 0 D Not To Scale I i. i. i. 4. n 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. rn Source of above Z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z ill TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE