HomeMy WebLinkAbout2026-00028810 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 111111111111111111 1111110111111 III �1I111I111�II
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 8
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00028810 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
BLUFF CITY BLVD Elgin
® ❑ RELATED ❑Y ®N 05 20 2026 ❑AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 05:16 ®PM FLOW CONDITION m
I 0 ®!MI N 0 S W Elizabeth St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW 16 '
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD El STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 5 /
yr 13-UNDER CARRIAGE 10l ! 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rn
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
M 2 4 0 0 ' 2
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI a , 4 COM VEH ❑ j$J 1 n
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 7 tz::LQ_-5 •I(Yes.See Sidebar U1 0
Z 2702814B IL 2026 REAR
TELEPHONE
IL D 0 3C6UR5CJ2LG217226 State Farm ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
62 2 Same 2770238SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED ) PEDAL 0 EWES 0
Yr!1 9 6 7 Other Other 00-NONE N_"j 12--_, DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10 :. 2 FIRE ID El U2 C
M 5 4 ❑Y El
IN ENGAGED ®-OTHER 9 16-TOP 3 0 X
❑N UNK VEH. AT CRASH 99-UNKNOWN `OistracI n Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-il a I:- 4 COMVEH ❑ ® U1 CO
FIRST CONTACT 15 7. � .5 •)ryes.See Sidebar C
H ELGINAR0)M IL 60120 0 1
IL D 0 NIA ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 3 1 Same NIA BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 13 1 05,20 ,2026 05 16 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 30 2 05,20 ,2026 05 16 mi PM ❑Construction *
<ov 3 0 ]$j CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
J ❑AM ❑Maintenance U2
- ®a, ARREST NAME Vega Renteria.Alberto 11-804-B 1512679 05,20,2026 05 20 ®pM
o1SLMT
U 11 1 CITATIONS ISSUED 0 PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME
AM, 0 Utility
30
T 2 El ARREST NAME Vega Renteria.Alberto 11-1402-A 1512678 05,20 ,2026 05 20 0 PM 0 Unknown work zone type U1
n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME Y
2 2 3 0 1512-Juarez-Huichapan.Juan 400 337-Thompson 07 ,07,2026 01 30 ®PM Am Workers present? ®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 -<
} }---_r----; INDICATE NORTH combination):or
-I
C
Not To Scale
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver �
i_ e _ i. e. (example:shuttle or charter bus):or 0
L A B J tuff?City?Blvd
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or lP
L }----------; unnz - 1. } } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
•for direct compensation(example:large van used for specific purpose):or
(`Lrib—iiiigmi
L L - } } } 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
13
Ir.. placarding(example:placards will be isplayed on the vehicle). XI
, CARRIER NAME Z
I -I
C.)`� ADDRESS D
W 455?Btuff?City?Blvd rn
CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_--------1 - USDOT NO. ILCC NO. m
73
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 Ell 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 VIM 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 2 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: 0 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