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HomeMy WebLinkAbout2026-00020030 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll 111111 011111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004207093 u, 1 U2 3 4 2 U, 4 U2 U, 1 u2 U199 U2 5 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202612026-00020030 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n N STATE ST El In01:35 ® ❑ RELATED 0 Y ®N 04 12 2026 ®AM El YES IX]NO U1 -< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m FT N E S W WEST RIVER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OFMOTOR 0 SLOW Cl) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 0 4 FOR DAMAGEDAREA(S) FROM TOWED U1 0 / ! Kia Motors Co tima 2013 00-NONE © s 0 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) Rodriguez Arenas. Ruben.A. mo yr 13-UNDER CARRIAGE 10 • 2 FIRE 0 ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m M 2 SY8 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it s 4 COM VEH El Ea 0 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.see sidebar U1 Z FM53337 IL 2026 Isui TELEPHONE IL D KNADM5A36D6164221 First Chicago ❑Y ®N U2 r ni in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Elgin Fire Same ILS1206693-01 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 12 _ C o 13-UNDER CARRIAGE 10 1 c. 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 9 - POINT OF &' 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y —'1:-4 COM•I sVSeeSidebar❑ ❑ C CO F` pEAR` C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 997 < RESP❑YD❑N NDER U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N ❑ 1 3 04 r 12 r2026 01 35 ®❑AM 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 � ;, 2 ® 37 3 28 08 ! / ❑PM• ❑Construction * Z3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME r ! ID PM ' o u ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 45 t 2ARREST NAME AM 7 ! r ❑❑PM ❑Unknown work zone type U1 Eln OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ - ❑AM Workers present? ❑ 1539-Vargas. Miguel 501 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••--, , ; 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 INDICATE NORTH � bn)or BY ARROW 2 Ismb usenatd or designed to transport more than 15 passengers including the driverC - (example:shuttle or charter bus):or 0 L L.___A.._.� I t Not 7b scan i 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0 I - } } } transportingemployees in the course of their employment(example:employee X 1 I 1 i transporte -usuallya van vehicle or type passenger car):or � L L.___a.._.' « J \ ti l ` ® I. } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C �' — for direct compensation(example:large van used for specific purpose):or O L ._i_. .I t 1 - t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III — — — — ', y y placarding(example:placards will be displayed on the vehicle). .Z1 r� •4.. r t t \, CARRIER NAME 1 1 1 Z I —I_ _ __ ADDRESS0 D C/) CITY/STATE/ZIP n i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other I. --- --• - 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 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U—COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: _Arties . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE