HomeMy WebLinkAbout2026-00005326 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X�004119904
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INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 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) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00005326 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
® ❑ RELATED PRIVATE ' V 0 N 01 28 2026 ®AM ❑YES ®NO U1
ALFT LN Elgin mo /day/yr 05:40 ❑PM FLOW CONDITION ITT
•
02040!MI NOS W BRITAN N IA Dr COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ElSLOW 1 (n
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
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑WIN 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) Mao TOWED U1 Q
ROSALES ALVA. IVANY 0 1
yr 13-UNDER CARRIAGE tU l !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 in
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL a I, 4 COM VEH 0 0 1 0
H 1- HUNTLEY NTLEY I L 60142 0 1 0 FIRST CONTACT 1 r: __5 *II Yes.See Sidebar Ul
Z DK40436 IL 2026 REAR
TELEPHONE
IL D WBAET37433NJ23027 ALLSTATE ❑y ®N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 VILLA. EMILY 979419396 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 c
N DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEOAL 0 EWES ❑NMV 0 Ncv ❑DV
yr 9) t2 2 FIRE 0 ® U2 C
o 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 10 7�_, .5 •It Yes.See Sidebar
H ELGIN IL 60123 0 1 0 G365674 IL 2026 I gSn
M
IL D 0 5NMSH13E77H031481 STATE FARM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 KI LE. RANDY 047487SFP13 BAG $
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)
1 3 09 / F 2 3 0 1 0
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/ / #OCCS D
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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 El 11 1 11 ,81 ,026 05 41 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
E, 2 ❑ 38 3 28 18
! 1 ❑PM• ❑Construction >F
1 4
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
-a, ARREST NAME ROSALES ALVA. IVANY 11-601-Ax 1558000143W t / El PM SLMT
o30N 1 ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
t 2 ❑ 41 3 ARREST NAMEAM
7 / / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ID Workers present? ❑Y 30
1558-Lundvick.John 901 , , ❑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
J ADDITIONAL UNITS FORMS.
r ----r••--, , I ® - ; A CMV is defined as any motor vehicle used to transport passengers or property and: z
�____r____; I , _ 1. Hasa or more than pound (example:truck or truck trailer_ 1. a weight rating10 000 5 -<
INDICATE NORTH Ilon):
BY ARROW c2 Is used or designed to transport more than 15 passengers including the driver C
} �Bf�Itnnla?Dr� I Not TO Scale I
----
- } (example:shuttle or charter bus):or 0
3. Is d ned tocarry 15 or fewer passengers and operated a contract carrier O
}_---------J.
I - } } 1. transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including N
--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L L____a____. ft G _ 5 Is any vehicle used to transport an hazardous material(HAZMAT)that requires -U
. � placarding(example:placards will be displayed on the vehicle). ,Zmt
41. -" D
CARRIER NAME
.# _ ADDRESS 0
AP* rn
I -0'� CITY/STATE/ZIP 0
G 'I . - MOTOR CARR.ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. 0 Not in Comm./Other 00
:- .I. --- --1 I - ii L i. L '
USDOT NO. ILCC NO. C
m
73
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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
Black 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 DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE