HomeMy WebLinkAbout2026-00002051 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ Mil Ill 11 IIIl DIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 107939
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00002051 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED PRIVATE ❑Y ®N 01 11 2026 ❑AM ❑YES ®NO U1 -<
N RANDALL RD Elgin mo /day/yr 03:16 ®PM FLOW CONDITION m
_
02540!MI N E O W Tall Oaks Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 /
yr VolkswagenQ 12 - tzl E
13-UNDER CARRIAGE to l 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SY4 ❑Y ONM DUNK VEH. 0 AT CRASH IN 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S �i COM VEH 0 0 1 0
ELGIN IL 60123 0 1 0 FIRST CONTACT 11 7_; -__5 *IIYes.See Sidebar U1
Z FB94091 IL 2026 REAR
TELEPHONE
IL D 0 1 VWBA7A35JCO22659 State Farm ❑Y Il N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0735291-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 l uv 0 Ncv 0 Dv
Yr 9 5 4 Subaru XV Crosstrek 2.0 2024 00-NONE 'o,I t2 c,-2 FIRE DUE El
CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0
POINT OF 8 i1�1" 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 5 Y:1 —_,SOS •If Yes.See Sidebar
Batavia IL 60510 0 1 0 5098612 IL 2026 I 0
IL D 0 4S4G U H M64R3809606 USAA ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same GIC 061466072 7101 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
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 r 11 )026 03 16 ®PM in a Work Zone? NJ DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 0 28 18 ) ) 0 PM• 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o1El 11 1 ARREST NAME Villarreal.Stephanie. N. 11-601 S1542-000641 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
T 2 ❑ 0 AM ARREST NAME 11 1 11 /026 03 30 0 PM 0 Unknown work zone type U1 45
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 45
1 542 Chafe. Ethan 602 21 r 71 ,026 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.
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E A CMV is defined as any motor vehicle used to transport passengers or property and:
01. Has a Z
8 weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i,
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i'----r----, Not To Scale - INDICATE
ARROW
BY
i. r r NORTH combination):or —I
2 Is used or designed to transport more than 15 passengers including the driver
(example:shuttle or charter bus):or n
T,3. Is designed to carry 15 or fewer passengers and operated by a contract career O
gill
I
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
_ - a 1 �4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
for direct compensation(example:large van used for specific purpose):or o
L L a < i. i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Iplacarding(example:placards will be displayed on the vehicle).
- CARRIER NAME Z
i N ADDRESS o
r� ri r CITY/STATE/ZIP_
_ i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1`! ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- gig - m
USDOT NO. ILCC NO.
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 VIM 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 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE