HomeMy WebLinkAbout2026-00008338 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 III 11 II I1 IIMI I U
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004138052
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00008338 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
COOMBS RD Elgin 04:01
® ❑ RELATED ❑Y ®N 02 12 2026 ❑AM ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
4 !MI N E COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
0 W Highland Ave Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
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Ara Mantilla. Hosman. D. Toyota Corolla 2009 OD-NONE 11_. t2 _, OUETOCRASH El ENE
NAME(LAST,FIRST,M) y mo yr 13-UNDER CARRIAGE 10 �. 2 FIRE ❑
02 1T1
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2
SYSTEM IN ENGAGED15-OTHER
M 2 4 0 0 9 76•T 3 _
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI a jl COM VEH 0 Ea 2 (7
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 4 7 : R-O =II Yes.See Sidebar Ut 0
Z FH39814 IL 2026
TELEPHONE
IL D 0 1 NXBU40E09Z062967 American Freedom ❑Y Il N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 12-2408121-02 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 2 eu
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0
1 9 9 6 Mercedes-Berf2300 2014 00-NONE 11_"i Qj I�O DUE TO CRASH 0 (� 2
13-UNDER CARRIAGE I FIRE 0 ® U2
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i1 4 5 lf�_ COM VEH ❑ ® U1 W
FIRST CONTACT 1 7�- -5 •If Yes.See Sidebar
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= Pingree Grove IL 60140 0 1 0 M I LOV WS IL 2026 REAR g f)
IL D 0 WDDGF8AB8EA945751 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 M I LOVYCH.YU RI I 2543086-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!!TELEPHONE) (EMS) (HOSPITAL)
1 3 10 / F 2 4 0 1 0
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/ / #OCCS D
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 02 r 12 r2026 04 01 ®AM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5
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2 ❑ 20 2 r r 0 PM 0 Construction
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R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Aray Mantilla, Hosman• D. 11-709-A W1543000337 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
45
t 2 ARREST NAME AM
r r ❑❑PM 0 Unknown work zone type U1
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T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
1543-Sturgeon, Kyle 900 337-Thompson r r ❑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••--, , I ; 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 truckrtrailer -<
i- }____r____1 I t _ combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
�� _ (example:shuttle or charter bus):or
ragmsne9l4s
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
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'I'— - }} } transporting employee 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 C}--- ----; - } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
i i. _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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13B011?9aoombe7Rd , , , , pMcarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
unn1 ADDRESS 0
�p .,
ICCITY/STATE/ZIPg
- MOTOR CARR.ID El Interstate El Intrastate
Intrastate 0
I I T I ❑ Not in Comm./Govt. Not in Comm./Other
Not To Scale I
0❑
USDOT NO. ILCC NO. m
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
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' -n
TRAILER 1 ❑ ❑ 0 Z
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TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
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/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE