HomeMy WebLinkAbout2026-00006623 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and!or Tow Due To Crash
❑AMENDED YR 2026I 2026-00006623 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
❑ ® RELATED ®Y 0 N 02 03 2026 ❑AM ❑YES ®NO U1
W HIGHLAND AVE Elgin10:06
_ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
U2 --I
El 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 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 C)
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Medina.Juan.C. Honda Accord 2005 00-NONE 0• 12 0DUE TOCRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 1 ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 0 m
M 2 5 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6.;il 6 4 COM VEH 0 El 4 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 __5 *II Yes.See Sidebar U1
Z EJ32763 IL 2026 E
TELEPHONE
IL D 1 HGCM56415A071221 State farm ®Y 0 N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
MEDINA.JUAN. M. K737413-E24-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0!My 0 NOV ❑DV
!1 9 9 1 Nissan Rogue 2019 00-NONE O': Q!•-O DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE 10 I ) 2 FIRE ❑ ® U2 C
F 2 5SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 9 X
0 Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac) n Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 6 .I. 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 12 O7 ,�=Q)OS C.
If Yes,See Sidebar C
ELGIN IL 60120 C 1 0 FA25433 IL 2026 REAR 9 fp
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IL D KNMAT2MT6KP557419 GEICO ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 6173-28-28-79 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 02,03 /2026 10 06 ®AM 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 C)
v 2 0 17 18 02,03 ,2026 10 O6 mi PM ❑Construction *
R O 0 ]$I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Medina.Juan.C. 11-601-Ax 1517-000521 02/03,2026 10 15 ®PM• ' El Utility SLMT
I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
8 N ❑AM 30
Ti 2 0 1 3 ARREST NAME Medina.Juan.C. 3-707 1517-000522 ( ! ❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1517-Le Cates. Brittany 600 337-Thompson 03 , 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 -<
` ` -'- ' r INDICATE NORTH combination):or .Z-1
,,1. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i A - } (example:shuttle or charter bus):or
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A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I. } } transporting employees in the course of their employment(example:employee
_ i transporter-usually a van type vehicle or passenger car):or w
L }-----}----; """ '"iaw are - } } } •4. Is used or designated to transport between 9 and 15
assen including the driver. N
fiKiuprr, _____ • for direct compensation(example:large van used fors specific purpose):or
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____a_ � � — t i i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m
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ter'~/ placarding(example:placards will be displayed on the vehicle). ;p
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,erii CARRIER NAME Z
ADDRESS 0
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Not To Scale I CITY/STATE/ZIP n
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MOTOR CARR.ID 0 Interstate ❑ Intrastate
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I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
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Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE