HomeMy WebLinkAbout2026-00036038 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004276345
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00036038 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 HIAWATHAm DR Elgin04:32
® ❑ RELATED ' V 0 N 06 21 2026 ❑AM ❑YES El NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W MARTIN DR COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR El SLOW 15 u)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —1
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04
FOR DAMAGEDAREA(S) FROhrr TOWED U1 0
Munoz. Maria. D. 1 0 /
yr 13-UNDER CARRIAGE O i FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0U2 04 M
F 2 4 ❑Y ®SNEM❑ n 15-OTHER
UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 00 TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� B �'.4 COM VEH 0 j$J 1 n
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 9 ®_; _-5 *If Yes.See Sidebar U1 0
Z FT83579 IL 2027 E
TELEPHONE
IL D 0 3WMX7B22PM370301 Statefarm ❑v ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
to
99 9 Munoz. Marciano 2523538-SFP-13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 X
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑114V 0 NOV ❑DV
'1 9 6 1 Subaru Outback 2021 00-NONE O, ' Qj O DUE TO CRASH p I1 2 x
o Yr 13-UNDER CARRIAGE I ( FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,19-TOP 3 X
❑Y ®N El UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
POINT OF s i1 I 4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7. 6`-5 •(ryes.See Sidebar
1= ELGINZ IL 60123 0 1 0 DN60273 IL 2026 REAR-5 0
IL D 0 4S4BTAFC7M3218525 Auto Club ❑y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same AUT700806713 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 4 06,21 l2026 04 32 ®pm El AM in a Work Zone? NJ N DIRP D
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
0 T
2 ❑ 2 23 , / ❑PM ❑Construction X
Z 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Munoz. Maria. D. 11-901-A 1569000107 ! ! El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
30
1 2 0 ARREST NAME AM
T 1 r ❑❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1569 Jaimes.Julian 200 - , , ❑AM Workers present? ❑Y
❑PM ®N U2 30
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,U:rEucSRk tO50AADDITIONAL UNITS FORMS.
A CMV is defined as any motor vehicle used to transport pasengers or property and: Zg orethan pound ( a p or truck trailer -<
1. Has a weight ratio m 10,000 5 ex m le:
i- }__-_r_-_-; I } combination):or
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver —I
_ } (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}.__-A-.-.� f [le—
- ; } } } transportingemployees in thecoursee of their employment
1114°
pbyment(example:employee
AA�rtlrrPDnw transporter-usually a van type vehicle or passenger car):or w
L }-----}----; urn?_ - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
aeexhrrm for direct compensation(example:large van used for specific purpose):or O
-` _ _ � i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a ir placarding(example:placards will be isplayed on the vehicle). 'D
I
11-:1
r L_i r CARRIER NAME Z
'0
` ADDRESS C
C)
I CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
Not To Scale O
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 USDOT NO. ILCC NO. m
XI
Source of above Z
. ❑ Yes 0 No 0 Unknown M
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
Xl
IDOT PERMIT NO. WIDELOAD-; 0 Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . 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