HomeMy WebLinkAbout2026-00004822 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III H
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) (8:1B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00004822 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
453 ADAMS ST Elgin 05:59
® ❑ RELATED ❑Y ®N 01 25 2026 12,— ❑YES ®NO U1 —<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ FT/MI NESW 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
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
FOR DAMAGEDAREA(S) FROPtf TOWED EN
U1 0Nunez. Maria.C. 0 1 /
yr 13-UNDER CARRIAGE ) ! FIRE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 0 DISTRACTED 0 U2 NI 1 I<i1
F 2 4 SYTM❑Y ®SNEDUNK VEH. O ATCRASHD 0 99-U 15-UNKNOWN THER9 76•TOP 3 `Distraction Value 7 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il a 4 COM VEH 0 El 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 O 7 ;1 _5 *IrYes.See Sidebar U1
Z CS44221 IL 2026 Ismi
TELEPHONE
IL D 0 4S3BNAS64J3016008 State Farm ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 3595088-SFP-13 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr Honda CRV 2012 00-NONE O, 12..-_, DUE TO CRASH rg ❑ 1 a7
o 13-UNDER CARRIAGE i 2 FIRE El ® U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 0 DISTRACTED 0 ® SPDR C)
0 0 16-
SYSTEM INENGAGED15-OTHER 9 TOP 3 9 0
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
POINT OF s ) U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR}._ C. VEH 0 ® C
F„ FIRST CONTACT 11 7 _,r_5 •If Yes.See Sidebar
FM75500 IL 2026aR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5J6RM4H7XCL065410 Farmers Insurance 0 Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Sajtar. Morgan. D. 540173129 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
iUNIT) (SEAT) (DOE)) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 4 07 / M 2 4 0 1 0
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/ / #OCCS D
71
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/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 01 /25 /2026 06 26 ®AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 28 05 / / ❑PM ❑Construction >F
Z3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
a1 ® 11 1 ARREST NAME Nunez. Maria.C. 11-601 S1542-000680 / / El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
r 2 El ARREST NAME 01/25 /2026 07 13 ®PM ❑Unknown work zone type U1 3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1542 Chafe. Ethan 701 02 / 17/2026 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 -<
i- }--__r-_--; } combination):or —I
N Not_To S_c1aM a INDICATE NORTH p3
-- - - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier enger car):or X
5
es pa g pe
I. } } transporting employees in the course of their employment(example:employee
co
L -----}---- \ - I. } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and 15
assen including the driver, C
for direct compensation(example:large van used fors specific purpose):or O
L t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
11R� 1 placarding(example:placards will be displayed on the vehicle).
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CARRIER NAME Z
urx
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 _ USDOT NO. ILCC NO. m
XI
Source of above z
'
. 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE