HomeMy WebLinkAbout2026-00019424 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110
1111111111
III IIIIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00042000,++
u, 9 u21 1 1 1 U1 2 U2 1 U199 1_12 1 U,99 U2 1 1 9 U123 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
®AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00019424 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
815 SUMMIT ST Elgin10:00 ❑PM FLOW CONDITION m
® ❑ RELATED ❑Y ®N 04 09 2026 ®AM ❑YES ®
PRIVATE mo /day/yr NO U1
_ _ g
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
1 2 !
EN
yr 13-UNDER CARRIAGE 101 •!. 2 FIRE 0 NI <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 M
M 9 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1 S �i 4 COM VEH 0 Ea 10
c Z ELGIN IL 60120 0 9 0 IL FIRST CONTACT 7 Y __s *uYes.See Sidebar Ut 0
Ismi
TELEPHONE
IL A 7 1J4RR4GG4BC534539 NONE El ®N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Estrada. Mayra NONE 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
0r RESPONDER 9G
0 DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr N_ 12 _1 ❑ 2 ,'�
o 13-UNDER CARRIAGE 10;1 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 +6.TOP 3 9
a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraction Value
POINT OF s ) Ut
H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR O 6 �!._ COM VEH ❑ ® CO
FIRST CONTACT 7 7 __, _5 •If Yes.See Sidebar
ZY97419 IL 2026 I 0 fp
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 5J6RW6H35HL000099 Economy Premier Assurance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Rudin. Merry.S. A7994304550 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 1 1 0 / F 1 4 0 1
m
/ / #OCCS D
71
/ / U1 1 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 ® 18 5 04,09 l2026 10 00 ®❑pM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0
2 18 99 + ! ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Estrada.Angel 11-404-A 399004524 r ! El PM SLMT
j$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N DI AM 99
r 2 El ARREST NAME Estrada.Angel 3-707 399004525 r r PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 99
399-Kazy-Garey. Daniel 202 334-Fries 05 , 19,2026 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.
Ir ----r•---, , Not To Scale 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--' j C-N)
- INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C} (example:shuttle or charter bus):or C
1 T,
I'!I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
< <---------•i I,
I--1 - } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
1 t C
} } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
• for direct compensation(example:large van used for specific purpose):or O
L i t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
—I
CARRIER NAME Z
yy ADDRESS 0, Y w
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
r -----------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. ❑ 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Gray
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