HomeMy WebLinkAbout2026-00046043 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
I III II IIIIII IUHI
U II Ili III I 111111
II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X -3Gb8a9`
u, 1 U21 3 4 2 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 U1 3 U2 11 *P 0119*
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-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00046043 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 07 31 2026 ❑AM ❑YES ®NO U1
N STATE ST Elgin 05:38
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
FT!MI N E S W W H I G H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 '
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 9 /
yr 13-UNDER CARRIAGE fa. !. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 R<1
M 2 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 976-TOP® `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 FIRST CONTACT 4 7 : •_O6 •Ir Yes.See Sidebar U1 0
Z ER33919 IL 2027 REAR
TELEPHONE
IL 0 JNKAY01 El6M102429 Safeway Insurance ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 38720941LPP007 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
/1 9 9 9 Mazda 3 2026 00-NONE 11_"1 Q1,O DUE TO CRASH ❑ 2 x
0Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c II
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6-TOP 3 X
0 Y NiN 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 ll, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _6 •(ryes,See SidebarC
= ELGIN IL 60120 0 1 FM77518 IL 2026 REAR 0
IL D 0 J M 1 BPBNYXT1855589 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 864874012 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DO8) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 05 / F 2 3 B 1
m
S/ / #OCC D
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 07/31 /2026 05 38 ®pm in a Work Zone? ®N DIRP co
1 r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
o"
2 0 2 99 ( ( ❑PM- 0 Construction *
R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
a1 ® 11 1 ARREST NAME Rivas Morales. Elder. N. 11-601-Ax 1515000794 / / ID PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑El Utility
r 2 0 ARREST NAME AM
T ( / PM 0 Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1515-BellEck.Stacy 601 393-Gutierrez / / ❑❑pM Workers present? ®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,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 truck trailer -<
- }____r__--; combination):or —I
INDICATE NORTH p1
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N _ } (example:shuttle or charter bus):or
Not To Scale ( 3. Is designed to car 15 or fewer passengers and operated by a contract carrier 0
J
} } } transportingemployees In the course of their employment(example:employee X
jCil Y transportr-usuall a van type vehicle or passenger car): r CO
C
L L.___a._...I 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
I. } } for direct compensation(examp large van used for speific purose):or (I)
L i — — — — t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—1
a. ( li _ CARRIER NAME Z
ADDRESS
%► n
I CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y._._.; - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
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
Gray White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 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