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HomeMy WebLinkAbout2026-00024449 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IIII UHI U� I� 11111 UI H OHIUII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 4223665 u, 1 U2 1 1 2 U, 8 U2 U, 1 U2 U, 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ® B Injury and f or Tow Due To Crash YR 2026I 2026-00024449 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n CHURCHILL DR Elgin ® ❑ RELATED ❑Y ®N 04 30 2026 ❑AM ❑YES El NO U1 -< PRIVATE mo /day/yr 04:23 ®PM FLOW CONDITION m 020CIF)!MI N E 0 W CHURCHILL DR/Cameron Dr COUNTY PROPERTY ®Y El'COUNTY DOORING ❑y #OF MOTOR 0 SLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 6 / yr 13-UNDER CARRIAGE ©10,I !�. 2 FIRE 0 ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i 4 COM VEH 0 Ea 1 0 0 ELGIN I L 60124 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 Z EQ80818 IL 2026 REAR TELEPHONE IL D 0 4T1 K61AKOLU924945 National General ❑v Igl N U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same 2028911512 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 X 0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 i CIRCLE NUMBER(S) U1 v 0 Dv yr O Nissan Rogue 2016 00-NONE al t2-.__, DUE TO CRASH 0 ❑ 2 x o ®13-UNDERCARRIAGE l c 2 FIRE ❑ El U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ SPDR 0 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0 a ❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value POINT OF 8it 4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��'`_ COM VEH ❑ ® CO FIRST CONTACT 11 7 _,__5 ••If Yes.See Sidebar H S773876 I L 2026 I:EAR 9 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 5N1AT2MV7GC852492 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Mendez Capilla. Mayra.C. 1267350-SFP-13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 04/30 �2026 04 23 ®pm 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 ❑ 28 15 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + / ❑PM- ❑Construction SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' ou ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT r 2 ❑ ARREST NAMEAM 'El 1 / ❑❑PM ❑Unknown work zone type 25 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1529-Audi red.Jonathan 901 393-Gutierrez / / 0 pM Workers present? ®N U2 25 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 nfl 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- `-- --I-- --' N - INDICATE NORTH combination):or -I II BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C V _ (example:shuttle or charter bus):or r r r 0 I- I- --I-- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X enger i_ I-----}----l. n /��- - • } } 1 •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15r including the driver. / \ for direct compensation(example:large van used for specific purose):or 0 L L____a____. j / i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires III placarding(example:placards will be displayed on the vehicle). m r1/4 / �' -1 D �� , CARRIER NAME Z I I` _ __ ADDRESS D w C) Churchill?Dr. CITY/STATE/ZIP g Not To Scale _ MOTOR CARR.ID 0 Interstate ❑ Intrastate I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. rn XI Source of above 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 Black White 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Other I Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE