HomeMy WebLinkAbout2026-00005223 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 0
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004123219
u, 1 U2 1 1 1 U1 9 U2 1 U, 1 1_12 U, 1 U2 1 5 9 U123 u221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00005223 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
818 S MCLEAN BLVD Elgin 06:41
® ❑ RELATED 0 Y ®N 01 27 2026 ❑AM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NW 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Penagos Yasno. Lisette 0 5 /
yr 13-UNDER CARRIAGE NI
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 9 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it 6 1, COM VEH 0 0 1 C)
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 6 O7 _;1 __5 *II Yes.See Sidebar U1 0
Z FY34434 IL 2026 REAR
TELEPHONE
IL D 0 2HKYF186X5H561932 First Chicago El ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
99 9 VALENCIA ARIZA.VICTOR.A. ILS125977300 4 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 As
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 IIUV 0 NDV 0 DV CIRCLE NUMBER(S) U1
yr 10' 12 c., 2 FIRE ❑ ® U2 1 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TOP3 0 ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'I- It 4 COM VEH ❑ ® u1 CO
FIRST CONTACT 7 7. B l'�.5 *If Yes.See Sidebar
H 3582260B IL 2026 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FTFW1 E63BFB30561 Auto-Owners ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Gentile. Robert.G. 54-271599-00 BAc $
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)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 01 /27 /2026 06 41 ®pm in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 30 28 / / ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
a1 ® 11 1 ARREST NAME Penagos Yasno. Lisette 11-402-A S1509000180 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
r 2 0 ARREST NAME AM
7 / / PM 0 Unknown work zone type 15
U1
2 2 3 IDOFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 15
1509-Wortman.Cassie 702 02 / 17/2026 01 30 ®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•--1 , , ; 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----; ; - 1 combination):or
INDICATE NORTH 71
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I ; - (example:shuttle or charter bus):or
etaze.arrcta«n�aw r r r n
e N D 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
-- - } } 1- transporting employees In the course of their employment(example:employee �7
Id transporter-usually a van type vehicle or passenger car):or CO:- a / I I i t I I I I I I I I I I I I I I I I } 1. 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver w
for direct compensation(example:large van used for specific purpose):or O
L L----a-- �I } } _ 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
, m
1^ I I I I I I I II I I I 1. placarding(example:placards will be displayed on the vehicle). 73
• D
CARRIER NAME Z
ADDRESS O
D
I I I E
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ElIntrastate -<
❑ Not in Comm./Govt. ❑ Not in Comm./Other OO
----- ._._ - USDOT NO. ILCC NO. m
• 1 Source of above Z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No —t
If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xi
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown E
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash? O
❑ Yes lI No El Unknown 0
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7(1
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 5
Z
Form Number 0
_ m
70
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No =
' TRAILER VIM 1 _ cn
m
LOCAL USE ONLY TRAILER VIN 2 m
— O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft N
Silver Maroon
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE