HomeMy WebLinkAbout2026-00043623 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X+ 18445
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INVESTIGATING AGENCY DAMAGE TO ANY El 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 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00043623 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 07 21 2026 ®AM ❑YES ®NO U1 -<
RANDALL RD Elgin mo /day/yr 09:05 ❑PM FLOW CONDITION m
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01 O�i!MI N E O W WESTFIELD Dr COUNTY PROPERTY ❑Y MN DOORING ❑y #OF MOTOR 0 SLOW 1 cn
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 Peon. 0 EWES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 8 n
FROM TOWED U1 Q
FOR DAMAGEDAREA(S) FRO
PEREZ ENCISO.ALEXIS. E. 1 0 /
yr 13-UNDER CARRIAGE } FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O " 2 DISTRACTED 0 0 U2 8 m
M 2 4 ❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 I,.4 COM VEH 0 Ea 1 O
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT OO 7_; _-5 *if Yes.See Sidebar U1
Z FX63306 IL 2026 E
TELEPHONE
IL D 0 1 HGFA16568L022533 STATE FARM ❑Y ®N U2 I--
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3846244SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER
ou
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g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EWES ❑
2 0 0 1 Volkswagen Passat 2014 00-NONE 1i_-1 12..-_, DUETO CRASH 0 2
.. -y Yr 13-UNDERCARRIAGE 10;i• c. 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
POINT OF 8 I .. 4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR � 6
FIRST CONTACT 7 l:l1� _5 •If Yes,See Sidebar C
HAM PS H I R E IL 60140 0 1 0 AS48627 IL 2027 I 0 Si)
IL D 0 1 VWBS7A31 EC109249 THE CI NCI N NATI INS.CO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
RICHTER.JAMES. P. A010763887 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 9 1 07,21 ,2026 09 05 ®❑PM AM in a Work Zone? NJN 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 C)
o"
2 10 99 , , 0 PM ❑Construction *
Z 3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a PEREZ ENCISO.ALEXIS. E. 12-101 244-1856 / PM "
-, ARREST NAMEEl
o u ® 19 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
45
T 2 ARREST NAME AM
7 El r ❑❑PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑y 45
244-Blomberg. Michael 901 275-Engelke 08 ,25,2026 01 30 ®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••--, , I I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
l 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }---------; I Not To Scale INDICATE NORTH combination)or
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C
3 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
B - (example:shuttle or charter bus):or
V' i T,
L A N 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 73
transporter-usually a van type vehicle or passenger car):or co
. 4. Is used or designated to transport between 9 and 15 passengers,including (I)
}-----;----; Ro - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
____a____. g l. i i i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). m
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CARRIER NAME Z
_ ADDRESS D
Cz a
0
.r CITY/STATE/ZIP 0
- MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T ❑ Not in Comm./Govt. ❑ Not in Comm./Other
T O
'----Y----4, I 1 - USDOT NO. ILCC NO. C
XI
Source of above Z
. ❑ Yes 0 No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
0 Yes II No ElUnknown 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
73
IDOT PERMIT NO. WIDELOAD? ❑Yes 0 No 2
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
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 . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE