HomeMy WebLinkAbout2026-00046408 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets _ 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2O26I 2026-00046408 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mCENTER ST El In03:58
® ❑ RELATED ®Y 0 N 08 02 2026 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W E HIGHLAND G H LAN D AVECOUNTY PROPERTY :IY ® N DOORING ❑y #OF MOTOR ❑SLOW 15 co
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 0
FOR DAMAGEDAREA(S) FRO DI E
0NAME(LAST,FIRST.M) Medina Santiago.Abimael mo /
13-UNDER CARRIAGE 10,1 2 0 FIRE ElSTREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 02 m
M 9 8 SY❑Y ❑SNEM®UNK VEH. 9 AT CRASHD15-OTHER
9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & ii_6 I,.4 COM VEH 0 0 2 O
F. FIRST CONTACT 12 7 ;— _5 *II Yes.See Sidebar U1
Z Aurora IL 60505 B 1 0 DS26305 IL 2026
TELEPHONE
IL D 0 1 G N ERG KWSLJ 126981 Kemper ®Y 0 N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Other 99 9 Same 12RA000075438 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
!1 9 4 4 General Motor-terrain 2016', 00-NONE 11 _.�j.-_1 DUE TO CRASH rg ❑ 2 x
.. 13-UNDER CARRIAGE Ic FIRE ❑ ® U2 C
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 00.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 94. 6 I!•_4 COM VEH 0 ® U1CO
FIRST CONTACT 8 4:;1Q1__5 ••ITYes,See Sidebar C
Palatine IL 60074 B 1 0 BF65108 IL 2027 0 Si)
Z
IL D 0 2GKALPEK3G6309708 StateFarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 0236821-SFP-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph 0 Y°ND
0 N U1 =
(UNIT) (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 0 Y U2 Z
N 1 ® 11 4 H&H Electric Company Light Pole NE corner 81 ,12 !26 03 58 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 2830 COMMERCE ST Franklin IP6rk 60131 05 2 81 ,12 ,26 03 58 pM
1
® • ❑Construction
N 3 0 I'i CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME Medina Santiago.Abimael 11-601 753502 81 ,12 !26 04 05 igi pM SLMT
o N 1 ® 11 4 •lgiCITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM
30
T 2 El ARREST NAME Medina Santiago.Abimael 3-707 753503 , ! 0 pM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1543-Sturgeon. Kyle too 91 , 12 ,26 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 truckrtrailer -<
i- }----------1 i
I. INDICATE NORTH combination)or -I
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L ( } ,. (example:shuttle or charter bus):or
I i Not To Scale 1 3. Is designed to car 15 or fewer passengers and operated a contract carrier O
I : I. } } transporting employees In the course of their employment(example:employee
CO
L •-----}----; ao - 1 •} } } transporter. sed or des gnated to transport betweelly a van type vehicle or n 9 and 15 passengers,including the driver.enger car):or X
awr for direct compensation(example:large van used fors specific purose):or O
ECM ANDS' L___-a..... - t l. I 1 _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ;p
® —I
Enyr�dtA� CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
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 Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
_Other . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE