HomeMy WebLinkAbout2026-00038610 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0043283 5
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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-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 2026I 2026-0003861 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
S MCLEAN BLVD Elgin 05:31
® ❑ RELATED ®Y 0 N 07 01 2026 12,— ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W ERIE ST COUNTY PROPERTY :IN Y ® DOORING Ely #OF MOTOR ❑SLOW 1 (/)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 5 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 (<Tl
F 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH 0 IN ENGAGEDis-OTHER
99-UNKNOWN 9 16•TOP 3 *Detraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�a 4 COM VEH 0 j$J 1 0
F. FIRST CONTACT 12 7 ;—, _5 *Irves.SeeSidebar U1
Z SOUTH ELGIN IL 60177 0 1 0 DS17250 IL 2026 REAR
TELEPHONE
IL D 0 5NMS2CAD2KH057776 National General ❑Y ®N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 2016925275 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0 NOV 0 DV CIRCLE NUMBER(S) U1
$ 1 9 yf 3 Jeep(after 1968,�rokee 2015 00-NONE i1_"j Q�,-_, DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10( I. FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S ... 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 O7 ,�-----: C.
If Yes.See Sidebar C
ELGIN IL 60123 0 1 0 GB19301 IL 2026 AR Si)0
IL D 0 1C4PJMCSOFW665325 The General ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same I L8819334 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 07,01 /2026 05 31 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 28 15 07,01 /2026 05 42 ®PM ❑Construction *
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Rudaini. Lana. N. 11-601 1556-200 07/01 /2026 05 46 Igi pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
t 2 El ARREST NAME 07/01 /2026 05 42 ®PM El Unknown work zone type U1 0 AM
3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1556-Sanchez.Jimena 601 320-Cox 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
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 -<
i- }---.r----; - } combination):or -I
INDICATE NORTH p1
lr 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
3. Is desgned to carry15 or fewer passengers and operated a contract corner
+...] I N I 1W
} } } transporting employee In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L L.___a.. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
EWA Pe ( P 9 Pe or o
L L____a..... 4r1 tr; � 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
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�'_-1 pWcartling(example:placards will be displayed on the vehicle). ;p
. 1
I >=� I _ CARRIER NAME Z
OrNotroscalelz.
ADDRESS D
•
CITY/STATEIZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i- --- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
• m
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 g
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
71
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. 0
Black Black
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE