HomeMy WebLinkAbout2026-00003753 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I0011110 10
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004112253
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00003753 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
N RANDALL RD Elgin06:14
® ❑ RELATED ®Y 0 N 01 19 2026 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W HIGGINS I NS RD COUNTY PROPERTY ❑Y I�1 N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 T TOWED U1 0
Inclan. Bladimir Ford Escape 2016 00-NONE ,, • 12 OUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE al
101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF S_iL S ii,4 COM VEH 0 Ea 1 0
FIRST CONTACT 1 7_;—_;__5 *Irves.SeeSidebar U1
V Z Carpentersville IL 60110 0 1 DS26627 IL 2026 REAR
TELEPHONE
IL D 0 1FMCUOG95GUC77425 Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same Unkown 3 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y ❑ N 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lily 0 i v 0 Dv CIRCLE NUMBER(S) U1
!1 9 6 9 FR
Acura Integra 1995 00-NONE 'o,1 (,-
t2 2 DUE rg U2 TO CRASH D 2 C
o 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 0 X
❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O)�n_i, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 7 7 _-__ _5 •If Yes.See Sidebar
Z Streamwood IL 60107 0 1 N128841 IL 2026 REAR0 N
M
IL D 0 J H4DC4351 SS040634 American Alliance ❑Y J N RDEF ZI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same I LAA-0551034-05 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND O N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 1 01 ,19 l2026 06 14 0 PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 0 28 15 ) ! 0 PM 0 Construction *
N 3 0 Ixi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMSARRIVED TIME 3
❑AM ❑Maintenance U2
o 1El 11 1 ARREST NAME Inclan, Bladimir 11-601-Ax S1529-000636 r r El PM SLMT
ljg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
o N DI AM 45
t 2 0 ARREST NAME Inclan. Bladimir 3-707 S1529-000635 r r PM 0 Unknown work zone type U1
•
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1529-Audi red.Jonathan 901 320-Cox 03 ,03 r2026 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
N?Randall?Rd. ADDITIONAL UNITS FORMS.
r -- r•---, ,� A CMV is defined as any motor vehicle used to transport passengers or property and: Z
l IY J 01. Has a weight rating more than 10,000 pounds{example:truck or truck trailer -<
} } ' ' \ E / r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee 73
M 4 v ' transporter-usually a van type vehicle or passenger car):or co
I I I i / ` C
i. i. __I.,.. - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
— —— — — for direct compensation(example:large van used for specific purpose):or o
L I $ l. } I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
r s placarding(example:placards will be displayed on the vehicle). XI
—1
— —— — — CARRIER NAME Z
__ _ unlit _ ___ _ O
oral? ADDRESS D
e rA
Higgins?Rd.
CITY/STATE/ZIP g
Not To Scale MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;____Y____, USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Green
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE