HomeMy WebLinkAbout2026-00025298 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004221408
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 202612026-00025298 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
1187 DUNDEE AVE El 04:12
® ❑ RELATED ❑Y ®N 05 04 2026 12,— ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Real. Nanci 0 6 /
yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED ❑ 0U2 02 m
F 2 SY4 ❑Y CITM NE
®UNK VEH. 9 AT CRASH 9 99-UNK 15- NOWN THER9 16•T DP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 �i 4 COM VEH 0 j$J 1 0
ELGIN N I L 60120 0 1 0 FIRST CONTACT 11 7_:( __5 *II Yes.See Sidebar U1
Z CW79626 I L 2026 REAR
TELEPHONE
IL D 0 2T1 BU4EE2DC008086 Progressive ❑Y igi N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 871261424 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nu,ly 0 NOV ❑Dv
/1 9 yf 6 Nissan Versa 2015 00-NONE 11 112 :-y FIREo CRASH ® U2 2 C
0 13-UNDER CARRIAGE III0
P.
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16•TOPQ * X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 1( 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 3 7 -5 *If Yes.See Sidebar
= ELGIN IL 60120 0 1 0 EE56920 IL 2026 RFJ
IL D 0 3N 1 CE2CPXFL420611 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 3680960-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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2 3 12 / M 2 4 0 1 0
U2 996 m
##OCCS y
/ /
23
/ / U1 01 ' D
/ / 02 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 05/04 /2026 04 12 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
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2 0 2 99 / / ❑PM• ❑Construction
4
Z 3 0 CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Real. Nanci 11-901-A W1567000036 / / El PM SLMT
j$!CITATIONS ISSUED ❑PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM•
T 2 El ARREST NAME Vences Jimenez.Agustin 6-101* 1567000035 05/04 /2026 04 20 0 PM El Unknown work zone type U1 25
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1567-Muehl.Claudia 201 06 /02/2026 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----T-•--, , ; A CMV is defined as any nmtor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` ' ' r INDICATE NORTH combination):or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Fob7Ave _ (example:shuttle or charter bus):or n
i r r r X
I- I- -I-
. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
w - } } } transporting employees In the course of their employment(example:employee
.�(fir transporter-usually a van type vehicle or passenger car):or CO
_''
J.
I.
-- % } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, (I),,..- '\ for direct compensation(example:large van used for specific purpose):or O
L i.____a____. _ t i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
—I
e _ CARRIER NAME Z
Not To Scale ADDRESS O
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CITY/STATE/ZIP g
- i. i. i. i. 4. MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I I- ❑ Not in Comm./Govt. Not in Comm./Other
"------"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? 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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE