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HomeMy WebLinkAbout2026-00036608 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III 11 IM UHI UU II III II�1 1001Y1 001 00000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XDC/421;C/86,7 u, 1 u21 3 4 1 u, 5 U2 1 u, 1 u2 1 u, 1 U2 1 5 10 u1 4 u2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ®5500 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 14 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00036608 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n ® ❑ RELATED ®Y 0 N 06 23 2026 DAM ❑YES ®NO U1 S RANDALL RD Elgin 09:05 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION III FT N E S W WELD RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FRONT TOWED U1 O Camarena. Rosa. M. Honda Odyssey 2025 00-NONE ©, 12 , DUE TOCRASH ❑ VI NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE 10.I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 0 171 F 2 4 SY❑Y ®SNE❑UNK VEH. 0 ATCRASHO 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH 0 j$J 1 C) Hampshire IL 60140 0 1 0 FIRST CONTACT 11 7_: __5 *If Yes.See Sidebar U1 Z P EZ48933 IL 2026 TELEPHONE IL D 0 5FNRL6H81 SB015137 Country Financial ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same P010835906 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 XI m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 Yr /2 0 0 4 Honda Odyssey 2015 00-NONE ,i_"j t2 -_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10 i 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,,6.TOPO3 * X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction Value 0 POINT OF s i1 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 6 1,,_ FIRST CONTACT 3 7 _, _5 •)ryes.See Sidebar = ELGIN IL 60124 0 1 0 7561170 IL 2026REAR C IL D 0 SFNRL5H65FB115322 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 David. Henry 1374387-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOE) (SEXI {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 12 11 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID N 1 ® 11 1 06/23 /2026 09 05 ®AM 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 o" 2 ❑ 06 99 / / ❑PM 0 Construction * 7 Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 a1 ® 11 1 ARREST NAME Camarena. Rosa. M. 11-801 W489000564 / / ID PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility T 2 ❑ ARREST NAME AM 7 / / pM El Unknown work zone type 45 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 489-Reynolds.Allison 800 / / El 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 -< c ` -' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees In the course 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 y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L : Dlapram?not?RequIred. l. } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D i placarding(example:placards will be displayed on the vehicle). ,Zmt —I CARRIER NAME Z ADDRESS 0 w n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rn XI Source of above Z . MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE