HomeMy WebLinkAbout2026-00021454 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 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 1215501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202612026-00021454 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
® ❑ RELATED 181 Y 0 N 04 17 2026 ❑AM ❑YES ®NO U1 -<
VILLA ST Elgin09:45
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NIAV ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 0 !
yr 13-UNDER CARRIAGE 10 IE
l ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SYTHER
4 ❑Y El CD UNK VEH. 9 AT CRASH M IN ENGAGED 9 99-UNKNOWNU 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I y COM VEH 0 0 1 C)
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 4 7 ; _O •IIYes.See Sidebar U1 0
Z BC19593 IL 2026 REAR
TELEPHONE
IL D 0 JTN KH M BX1 K1022410 State Farm ❑Y Igl N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
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Betran Roman, Maria, D. 3661234-SFP-13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCV 0 DV CIRCLE NUMBER(S) U1
!1 9 yr 8 Mazda 6 2014 00-NONE O, 12 -_, DUE TO CRASH 0 2
0 13-UNDER CARRIAGE 10 1 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N El UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 g
POINT OF 8 i1�i 4 COM VEH 0 ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 11 7 _6 •If Yes.See SidebarC
Z Joliet IL 60404 0 1 0 EG75931 IL 2026 I 0
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IL B 7 J M 1 GJ 1 U57E1100752 Progressive ❑Y 123 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 872311719 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),(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
u 1 ® 11 1 41 ,71 ,026 10 10 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 20 15 { ) 0 PM ❑Construction *
Z3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 4
o 1 ® 11 1 ARREST NAME Benitez,Carlos, D. 11-801 359000639 , ! El PM SLMT
l$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
S' N ❑AM 30
t 2 El ARREST NAME Benitez,Carlos, D. 6-101-A 359000640 , r ❑PM 0 Unknown work zone type U1
2 2 3 0 10
OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
565-Villagomez, Mireya 401 337-Thompson 51 , 21 ,026 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; ; } } } i- -, , ; ; , 1, ( 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
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3. Is
. L.-_------ 1 ____.... J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or c0
I- <.__-a-_-_- , l• I• I- <--_-a____� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L-. ._i_. -_.: L L L ...._-..i._ j l. 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
CARRIER NAME Z
i.
ADDRESS 0
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
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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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE