HomeMy WebLinkAbout2026-00007593 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10011110 llfl 100I110110000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004132348
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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 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and f or Tow Due To Crash YR 202612026-00007593 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 02 09 2026 ®AM ❑YES ®NO U1 -<
N LIBERTY ST Elgin08:32
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W ALGONA AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 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®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FRO T TOWED U1
General00-NONE 11 OUETOCRASH ❑
NAME(LAST,FIRST,M) M EDI NA LAR&CESAR. I. mo yr Motor's 2015��
13-UNDER CARRIAGE 101 12! 2 EN E
FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 m
M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 9 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $• iI B �I COM VEH 0 j$J 1 n
F. FIRST CONTACT 1 7 _ --_;__5 *IIYes.See Sidebar U1 0
Z CARPENTERSVILLE IL 60110 0 1 EJ32998 IL 2026 IlfAR
TELEPHONE
IL D 0 1 G KSG KC5FR513515 MAG N I U M ❑Y ®N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ILC8212829 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWes 0 NIAV 0 Ncv 0 Dv
/1 9 9 3 M Toyota Camry 2007 00-NONE 01.' 12 "_, DUE TO CRASH ❑ 2 x
0 yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ El U2 C
c
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 9 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distracter(Value
POINT OF 8 i1 li 4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR j 5
FIRST CONTACT 11 7 5 •(ryes.See Sidebar
n ELGIN IL 60120 0 1 EF47158 IL 2026 I:EaR 0
Z
IL D 0 4T1BE4627U113974 KEMPER ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 12AU001115434 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N 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
AM N 1 CD 11 4 co
02 r 09 /2026 08 32 ®❑PM in a Work Zone? NJ DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
F.; T 2 ❑ 2 28 1 / ❑PM ❑Construction *
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
4 ARREST NAME / / ❑PM '
o N 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • [3 Utility
SLMT
30
I 2 ❑ ARREST NAME AM
T 1 1 O PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
374 Rizzu o. Michael 201 / / El 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
enIBIErsmar Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer 1 -<
i- }---.r----; I } combination):or
INDICATE NORTH
1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
Not To Scale r r
3. Is designed to carry15 or fewer passengers and operated a contract carrier
< ----------.i
} I- 1. transporting employee In the coursee of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
I.
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
}--- ----+ - } } } g po passen rs,includi the driver,
ALOONu?ure for direct compensation(example:large van used for specific purpose):or O
L i____a____J .i` ` _ t i. i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
'am, - placarding(example:placards will be displayed on the vehicle). ;p
D_
`tA~'•. CARRIER NAME Z
N
.o _ __ ADDRESS D
CITY/STATE/ZIP 0
g
- i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
XI
Source of above Z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El 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'; ❑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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Silver
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE