HomeMy WebLinkAbout2026-00040773 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 11 1����� mil U �l III
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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 ®5501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00040773 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m825 S RANDALL RD Elgin04:10
® ❑ RELATED 0 Y ®N 07 07 2026 ❑AM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 5 !
yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,.it 6 1i, COM VEH 0 18! 1 04
F.
IL 0 1 0 FIRST CONTACT 7 tZ_: --5 *If Yes.See Sidebar U1 0
Z BL72894 IL 2026
TELEPHONE
IL D 3VV2B7AX6KM130874 Erie Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Nieto.Gustavo Q060216530 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 i v 0 Dv
yr 13-UNDER CARRIAGE 10I i., 2 FIRE 0 ® U2 C
a
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ® SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraci n Value U1 9 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A��',_ COM VEH ❑ ® CO
FIRST CONTACT 1 Y -5 •• •It Yes.See Sidebar
H DV68031 I L 2026 RFJ 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
SFNRL5H68BB089213 Geico ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Nieves.Victor.m. 4487566764 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEATI (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 07,08 l2026 05 27 ®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 ❑ 30 18
N 3 0 ❑CITATIONS ISSUED 0 PENDING / / - ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME / / ❑PM '
IS
® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
10
t 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 560-Martirez.Samantha 702 337-Thompson , ! ❑❑PM Workers present? ®N U2 10
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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; ; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or —I
P1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i I , } (example:shuttle or charter bus):or
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3. Is
. L.-_------ 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
transporter-usually a van type vehicle or passenger car):or c0
< <.__-a-_-_- , l• < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L---------_.: L L L ...._-..:__ ; t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zt
CARRIER NAME Z
ADDRESS 0
T.
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
73
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No Z
Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE