HomeMy WebLinkAbout2026-00030008 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111
I0110
II IllIllU
II I001 1111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004246943
u, 1 U21 3 4 1 U1 1 U2 1 U1 1 U2 1 U1 1 U2 1 3 10 U, 1 U2 -3-1 .P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00030008 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 26 2026 ®AM ❑YES ®NO U1 -<
BIG TIMBER RD I RANDALL RD Elgin04:59
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
!MI N E S W Bigtimber rdlrandall rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS O
(g:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EouES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
T TOWED U1 Q
NAME(LAST,FIRST,M) mo yr
Arvizu Hernandez. Ma Del.C. Honda CRV 2026 00-NONE EN
13-UNDER CARRIAGE ,, !12 DUE TOCRASH ❑
I IE
FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 0 m
F 2 SYTM IN ENGAGE15-OTHER
7 ❑Y ®SNE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TIDP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL S �i 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar U1
Z FS80471 IL 2027 REAR
TELEPHONE
IL D 3CZRZ2H5XTM760716 State Farm ❑Y ®N U2 1--
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Perez Arvizu. Daniel 1796755-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
�{rg- DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑ uv 0 Ncv ❑Dv
2 0 0 1 Ford Edge 2011 00-NONE 'o.r t2 (,�2 FIRE DUE ID
CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Oistracton Value 0
POINT OF S I jl 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 5 7�� —_,SOS •(ryes,See Sidebar
Oakwood Hills IL 60013 0 1 0 BM84335 IL 2026 REAR
0 N
IL D 2FMDK4KC3BBA84242 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Ali. Malyun ILAA-1045182-01 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
m
/ / ##occs y
Pj
/ / U1 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 05,26 ,2026 04 59 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
453. 2 ❑ 28 99
N 3 ❑ 0 CITATIONS ISSUED ID PENDING + ❑pM, ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM "
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utili45
ty
SLMT
t 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D El AM Workers present? ❑Y 45
1547-Steele.Justin 502 , , ❑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••--, , I Not To Sago i A CMV is defined as any motor vehicle used to transport passengers or property and: Z
II I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' I I I ff - I. INDICATE NORTH combination):or
t � BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver —I
/ l I I I 'J _ } (example:shuttle or charter bus):or 0
0
L --- ---•; I I I I I ` transporting employened to es inthe course passengers5 or fewer thir emplod yment example:employeener X
} } } }
II I I . . . transporter-usually a van type vehicle or passenger car):or �
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 ge ng C
} } } g po passen rs,includi [he driver,
___.: t� _ _ - i i L 5 r direct Is any vehicclle used to transport largeon(example:a hazardous for specific material(HAZMAT)):or
that requires
placarding(example:placards will be any
on the vehicle). XI
- - uott1 — - - -- - -- —1
CARRIER NAME Z
ADDRESS
I II
CITY/STATE/ZIPC)
Il
I I 11 I MOTOR CARR.ID 0 Interstate El Intrastate
I I I ❑ Not in Comm./Govt. Not in Comm./Other C
Y
r I I i. USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE