HomeMy WebLinkAbout2026-00021434 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III 11 IIII
UHI U� I� liii UU I� 11111110DD
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004206555
u, 1 U21 1 1 1 u1 2 U2 ' u, 1 u2 1 u, 1 U2 1 4 11 u1 1 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00021434 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 7
N LIBERTY ST Elgin 08:05
❑ ® RELATED ❑Y ®N 04 17 2026 ❑AM ❑YES ®NO U1
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
O0 !MI N E S W Enterprise St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn
p Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
(8:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/1 9 6 5 Toyota Camry 2014 00-NONE „ O i"_, OUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 , 2 FIRE ❑ ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 m
F 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 99-UNK 15- NOWN THER9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL s 4 COM VEH 0 Ea 1 0
I .
Hanover Park IL 60133 0 1 0 FIRST CONTACT 12 7 ; _5 *lIVes.SeeSidebar U1
Z BE73309 IL 2026 REAR
TELEPHONE
IL D 4T1 BF1 FK7EU782301 State Farm ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 Same 04-60065-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 My 0 NOV 0 DV
/2 0 0 5 Yr Toyota Camry 2010' 00-NONE ,�_"j Q�-_, DUE TO CRASH p 2
0iI 13-UNDER CARRIAGE 10( I FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracl n Value 0
POINT OF s i 4 COM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 O7 -L"_i�_OS •If Yes,See Sidebar
ZStreamwood IL 60107 0 1 0 FM70387 IL 2026 aR 0 N
M
IL D 1 NXBU4EEOAZ216221 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 Same 979538590 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (D00i (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
3 3 10 /
:A
/ / UI 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 04 r 17 l2026 08 05 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
T
0 2 0 2 03 r r ❑PM ❑Construction
Z3 0 I!!I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 5
o ❑ 11 1 ARREST NAME Valdovinos. Rosa. M. 11-601 S1573000051 / ! El PM SLMT
o N
•
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
35
r 2 11 1 ARREST NAME AM
T r r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 35
1573-Beasley. Maltese 201 320-Cox 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.
0IF 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-----; L combination)or
'c INDICATE NORTH p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
2 I - r (example:shuttle or charter bus):or 0
j 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
�. --I--• i ` }} } transporting employee in the course of their employment(example:employee
or 73
< �.___a____. _ 1 42lsuosedordrter- esgnatedtotranslly a van type portbetweeicle or n9a d15enger rpassen rs,includingthedriver,
0
Enterpriee9St } } } for direct compensation(examp large van used for specific purpose):or 0
L L._._a..... - `� - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
-I
4r1CARRIER NAME Z
ADDRESS '.Z
N V)
C)
MOTOR
I
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T ❑ Not in Comm./Gout. Not in Comm./Other
I
Not To Scale 1 USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard 0
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?
❑ Yes II No ElUnknown A
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. w
Red Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE