HomeMy WebLinkAbout2026-00020122 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00020122 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 04 12 2026 ❑AM ❑YES ®NO U1
PROSPECT BLVD Elgin01:17
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W SLADE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 '
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 7 /
yr 13-UNDER CARRIAGE -) FIRE ❑ lE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 h O DISTRACTED 0 0 U2 2 m
F 2 4 0 Y ®SNEM❑UNK VEH. O AT CRASH IN ENGAGEO 99-UUNKNOWN 9 16_TOPO ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH 0 0 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 3 7 ; __5 *II Yes.See Sidebar U1
Z BN61991 IL 2026 E
TELEPHONE
IL D 0 1 N4AL2AP6AN547836 State Farm ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 Sixtos.Stephanie 3875144-SFP-13 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ uv 0 NCV ❑Dv
$ 1 9 5 5 Nissan Rogue 2016 00-NONE O,` Oj'O DUE TO CRASH ❑ 2
o yr 13-UNDER CARRIAGE 1a� 1.. 2 FIRE 11 ❑ U2 C
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F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_i 6 1� 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 Y�� , =5 *IfYes.See Sidebar C
ELGIN IL 60120 0 1 0 ZY40747 IL 2026 I 0 N
IL D 0 JN8AT2MV4GW144143 Progressive Northern Insu ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X
99 Same 869746038 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND N 9 Ui =
KNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
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N 1 CD 11 4 04,12 (2026 01 20 0 pm in a Work Zone? ®N o1RP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1
0 T 5 n
2 0 2 99 / ( 0 PM- El Construction X
7
Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Ruiz.Alexandra 11-1204-B 434001412 / ! 0 PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
30
r 2 ARREST NAME AM
T ( r ❑❑PM 0 Unknown work zone type U1
El
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
434-McNamara.Shane 102 05 , 12(2026 01 30 ®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 -<
i- }--__r-_--; combination):or
Provo INDICATE NORTH p0
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r r r (example:shuttle or charter bus):or 0
r 'a
fq 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
1 } } } transporting employee in the course of their employment(example:employee
it)
Not To Scale 1 transporter-usually a van type vehicle or passenger car):or w
L L____a____� C
4. Is used ordesi natedtotrans rtbetween9and15passengers,induding[hedriver,
} } for direct compensation(examp large van used for speific purose):or
L L____a____.I —Moo— gime) — — — _ t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i— piacartling(example:placards will be displayed on the vehicle).
1 - CARRIER NAME Z
1
ADDRESS 'n
[II r :- :- :--
V)
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
XI
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 M
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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Black Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/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 ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE