HomeMy WebLinkAbout2026-00047898 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mill III H IIII
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202612026-00047898 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I
N LIBERTY ST El In05:58
® ❑ RELATED ❑Y ®N 08 09 2026 DAM YES ®NO U1 -<
g PRIVATE mo /day!yr ®PM FLOW CONDITION m
1 0 !MI N E S W East Chicago St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
® 0 g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑wcv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROf T TOWED U1 Q
g NAME(LAST,FIRST,M) mo
1 9 9 6 Nissan Pathfinder 2018 00-NONE „ • Q 0 OUETOCRASH ❑ VI
13-UNDER CARRIAGE i 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
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M 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 I,.4 COM VEH 0 LK 1 O
~ ELGIN I L 601 20 0 1 0 FIRST CONTACT 1 7_'mai-5 *II Yes.See Sidebar U1
Z EA54745 IL 2027 E
TELEPHONE
IL D 0 5N1DR2MM4JC664149 NIA ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Beltran. Mariana NIA 1 I—
t HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑
1 9 9 7 Chevrolet Cobalt 2008 00-NONE ,�_"j 12..-_, DUETO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10'I c. 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistracI on Value 9 0
H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF
T CONTACT 7 /l�11.QI_5 CIO�VEH See Sidebar ® U1 CO
E LG I N IL 60123 0 1 0 G F44660 IL 2026 l! 0 Si)C
IL D 0 1 G 1 AK55F377367638 Magnum Insurance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same I LA021222 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 997 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 1 08/09 ,2026 05 58 ®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
0 2 ❑ 28 03 , , ❑PM ❑Construction *
Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Delgado. Noe 4 753571 , , El PM
o u 1 ® - • 0
Utility
1 1 1 igiCITATIONS ISSUED 0 PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM
t 2 El ARREST NAME Delgado. Noe 11-601-Ax 753570 08/09 ,2026 06 30 0 PM El Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1526-Walsh.Jacob 302 09 , 14/2026 09 00 0 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 r INDICATE NORTH combination)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- ---I i } } } transporting employees in the course of their employment(example:employee
E?Chlcago?St transporter-usually a van type vehicle or passenger car):or co
L L.___a__ .. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } • for direct compensation(example:large van used for specificpurpose):or [he driver,
-_ __ _ - Pe ( P 9 Pe or
L t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
-I
CARRIER NAME Z
ADDRESS
Not 7b Save I T.
2 -,I of
�' CITY/STATE/ZIP n
?Liberty?Sti. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 r;r 0
I I T I I° ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; - USDOT NO. ILCC NO. rTt
XI
Source of above 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 0 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.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE