HomeMy WebLinkAbout2026-00012825 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 HH 1111 II MUH
U II IlU
M MI II
1111111
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004160051
u, 1 U21 3 4 1 U1 1 U2 2 U, 1 1_12 1 U,99 U2 1 5 11 U1 1 U211 *P 0119*
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 1215501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00012825 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
N LIBERTY ST Elgin10:00
® ❑ RELATED ❑Y ®N 03 06 2026 ❑AM D YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W E GH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ 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 ❑ PED ❑PEDAL ❑EWES ❑uuv ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGEDAREA(S) FRONT TOWED EN
U1 0Es inoza. Leslie.G. 0 4 /
yr 13-UNDER CARRIAGE ) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
F 2 SY 15-OTHER
4 ❑Y ❑SNE®UNK VEH. 9 AT CRASH M IN D 9 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI e 4 COM VEH ❑ j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *II Yes.See Sidebar U1
Z FR51916 IL 2026 E
TELEPHONE
IL D 9 1 C4RDJDOFC750367 First Chicago Insurance C ®Y ❑N U2 13 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LS 1295636-00 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 0
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑New ❑NCV ❑Dv
!1 9 yf 8 General Motorl9,ti ip 2013 00-NONE ,t-1 12"-_, DUE TO CRASH ❑ C 2
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S .,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar
H ELGIN IL 60123 0 1 0 DZ74110 IL 2027aR 9 Sn
M
IL D 0 1GKKVPKD8DJ235706 Allstate ®Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 975662072 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
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 03,07 /2026 09 00 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
Fsi 2 ❑ 28 18
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING • + ! _ ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ❑PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
SLMT
30
r 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
565-Villagomez, Mireya 301 — 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
co
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 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