HomeMy WebLinkAbout2026-00040328 I LLI NOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II I I H I M UHI U I� III IMI 1111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004298098
u, 1 U21 1 1 1 U11 O U2 1 U, 1 u2 1 U, 1 U2 1 1 12 u1 2 u2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2026I 2026-00040328 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2
® ❑ RELATED PRIVATE ❑Y ®N 07 07 2026 ®AM ❑YES ®NO U1 -<
S LIBERTY ST Elgin mo /day/yr 07:16 ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑'' #OF MOTOR ❑SLOW 2 Cl)
®20�F !MI N E O W Dixon Ave WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑'' ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2
FOR DAMAGEDAREA(S) FR0f4r TOWED U1 0
Luna. Karina 1 2 /
yr 13-UNDER CARRIAGE 10IE
I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SYTM IN ENGAGE4 ❑Y ®S NE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN x
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.;II 6 1i COM VEH 0 g 1 C)
F. FIRST CONTACT 4 7 _,-_;_OS •IIYes.See Sidebar U1 0
Z Sleepy Hollow IL 60118 0 1 0 2520709B IL 20 REAR
TELEPHONE
IL D 3TMCZ5AN3KM199667 American Family Insurance ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Luna-Robles. Ubaldo 41086-27370-66 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
L Refused RESPONDER >
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
1 9 8 2 Ford Ranger 2010' 00-NONE O,' t2 f.R"_, DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10 I 2 FIRE ID El U2 C
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-ill:, 4 COM VEH D ® U1 CO
FIRST CONTACT 11 7�_, _6 •(ryes.See Sidebar
n ELGINREAR
IL D 1 FTKR1AD5APA04818 State Farm ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3661234-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
0 N U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 Garcia. Maria.J. Landscape rocks and grass 07,07 ,2026 07 16 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
;, 2 ❑ 1 3 916 S LIBERTY ST ELGIN IL 60120 04 99 , , PM
❑ , ❑Construction *
Z 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
oER 11 1 ARREST NAME Luna. Karina 11-1101-A 1575000017 / ! ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
r 2 ARREST NAME AM
7 El r ❑❑PM ❑Unknown work zone type U1
2 Cf 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 3O
1575-Williamson.Colin 401 08 +04/2026 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
I O0e1°!iii.) 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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
- 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}. A_._.�
} } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
' ' -1 C
< < -- �---- ---- s - } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, (
`"� �[A . } } •
for direct compensation(example:large van used for specific purpose):or_
I I i
I- I---_-a_ } } } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
pW rncartling(example:placards will be displayed on the vehicle). ;p
-00.' CARRIER NAME Z
..1r ADDRESS 0
illi
-4449,*,14rAik, T.
CITY/STATE/ZIP 0
t - i. 4. MOTOR CARR.ID 0 Interstate El Intrastate
I I T I 11 ❑ Not in Comm./Govt. 0 Not in Comm./Other
;....Y_ _. I - USDOT NO. ILCC NO. m
XI
Source of above z
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El 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'; ❑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' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . 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