HomeMy WebLinkAbout2026-00033976 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 111111011 00 00110 00
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004269.55
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00033976 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
NATIONAL ST Elgin
® ❑ RELATED ❑Y ®N 06 13 2026 ❑AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 06:01 ®PM FLOW CONDITION M_
00 0/MI N 0 S W 65 National St COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR ElSLOW 15 '
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18: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) FROr�tr TOWED U1 O
Alexandra. Medina 1 0 /
yr 13-UNDER CARRIAGE NI
10 1 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rrl
F 2 4 ❑Y ®SYNNEM❑UNK VEH. 0 ATCRASHD 0 99-UUTHER NKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1,.4 COM VEH 0 Ea 1 O
~ Hanover Park IL 60133 0 1 0 FIRST CONTACT 12 7 ; _-5 *If Yes.See Sidebar U1
Z EV91468 IL 2026
TELEPHONE
IL D WBA8A3C54JA505301 State Farm ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Medina.Juan.C. 2928786SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 r uv 0 i v 0 DV
/1 9 9 3 Ford Bronco 2025 00-NONE 1("j 12--_t DUE TO CRASH ❑ 2 x
o 13-UNDERCARRIAGE 101 2 FIRE 0 ® U2 C
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN •0istracton Value 0
POINT OF s i 4 COM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 7 -�IOS •ItYes.See Sidebar C
Issaquah WA 98027 0 1 0 FN79736 IL 2026 REAR
0 Si)
Z M
WA D 3FMCR9CN1 SRE26504 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 865045249 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)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 11 / F 2 4 0 1 0
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/ / #OCCS D
/ / UI 2 D
/ / 1 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 06/13 /2026 06 01 ®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
o"
2 28 99 / / 0 PM• ❑Construction *
1
Z 3 0 xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
oEl 11 1 ARREST NAME Alexandra. Medina 11-601 1545-685 / / El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 0 ARREST NAME AM
7 / / pM El Unknown work zone type 30
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1545-VanEycke. Brier 401 337-Thompson 07 ,28/2026 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 truckrtrailer -<
r__--; INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
I I Not To Scate 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
— } } } transporting employees in the course of their employment(example:employee X
I I Imi transporter-usually a van type vehicle or passenger car):or w
L }- --}----; - - - } } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
I I 2r, for direct compensation(example:large van used for specific purose):or 0
=0 MI
L L____a____� DIEM t i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
�p 1placarding(example:placards will be displayed on the vehicle).
�` ,: .. CARRIER NAME Z
ADDRESS 0
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— mi CITY/STATE/ZIP
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i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
, , ,
r -----Y---'1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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
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
White Black
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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE