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HomeMy WebLinkAbout2026-00033393 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 10110 II liii lflfl 11f1 1110II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004273009 u, 1 U21 2 4 2 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202612026-00033393 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1 ST CHARLES ST Elgin 08:58 ® ❑ RELATED ®Y 0 N 06 10 2026 12,— ❑YES ®NO U1 _ _ PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 5 / yr Nissan Sentra 2022 00-NONE ® El. ©• 0 13-UNDER CARRIAGE DUE TO CRASH FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) Cy DISTRACTED ® 0 U2 2 rn M 2 SY8 ❑Y ❑STM NE®UNK VEH. 9 AT CRASH 9 99-UNK 15- NOWN THER9 16•TOP 3 *Distraction Value 6 ALGN X. V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :i1 B 4 COM VEH 0 j$J 1 0 I . ELGIN I L 60120 B 1 0 FIRST CONTACT 12 7_; _5 *IIYes.See Sidebar U1 Z DP39513 IL 2026 Ismi TELEPHONE IL D 3N1AB8DV3NY300747 NONE ❑Y ®N U2 I— M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Garibay,Gabriella, R. NONE 2 To HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r 2 X N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 /1 9 9 4 Dodge Charger 2014 11 00-NONE _ ©M j'-_1 DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE FIRE 0 ® U2 C il M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 00 TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistracuDn Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O1 '.4 COM VEH ❑ ® U1 W FIRST CONTACT 11 Y� _5 • C ZCarpentersville IL 60110 0 1 0 FQ73158 IL 2026 I , Irves.See Sidecar 0 Si) D IL D 2C3CDXHGOEH303136 Bristol West ❑Y J N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same G01403385602 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL) 1 5 04 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z U 1 ® 11 1 City of Elgin.City of Elgin Stop Sign 06,10 /2026 08 58 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 0 150 DEXTER CT ELGIN IL 60120 28 23 06,13 ,2026 08 58 PM ® • ❑Construction >F R 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 z J ❑AM ❑Maintenance U2 o ER 11 1 ARREST NAME Samayoa.Cristian.A. 11-601 SO475000736 06/13/2026 09 00 Igi PM SLMT I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NON . ROAD CLEARANCE TIME AM• ❑Utility o t 2 El ARREST NAME Samayoa,Cristian,A. 6-101 SO475000735 06/13 /2026 09 30 0 PM El Unknown work zone type U1 35 2 2 3 0 - OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 475-Willians. Brianna 401 07 , 14,2026 09 00 ❑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••--, , ; 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 truck trailer -< ` ` -' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I - } r r ,. (example:shuttle or charter bus):or 0 . r r i �► 3. Is designed to carry15 or fewer passengers and operated a contract carrier O NI - } } } transporting employee In the courses of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or CO L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or MINIMA o L ` ` ' ___.1 - - vwur - t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m 1 placarding(example:placards will be displayed on the vehicle). m 0 �♦ I CARRIER NAME Z wxerrrrr ADDRESS O Not To State I VV) CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate 0 Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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 71 IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2 TRAILER VIN 1 m to 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 Gray Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE