HomeMy WebLinkAbout2026-00050782 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00050782 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
1350 E CHICAGO ST EIIn04:09
® ❑ RELATED 0 Y ®N 08 22 2026 ❑AM ❑YES ®NO U1 '<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 2 fA
❑ FT/MI N E S W Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
ZAVALA.VALERIA 1 0
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 NI <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 2 4 SYTM❑Y ®SNE El UNK VEH. 0 AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a iI all 4 COM VEH 0 LK 1 0
H 1- EAST DUNDEE IL 60118 1345 0 1 0 FIRST CONTACT 6 I�::LQ_Q •If Yes.See Sidebar U1 0
Z FJ34421 IL 2026
TELEPHONE
IL D 0 1 N4AL3AP5FN331070 ALLSTATE ❑Y ®N U2 1--
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 947831963 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused El ou
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N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 KCv 0 DV
yr 19) 12 ( 2 FIRE ❑ ® U2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 X
❑Y MN DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 1,;,_ COM VEH ❑ ® U1 CO
FIRST CONTACT 3 7 .'_, -5 •If Yes,See Sidebar
4 ELGIN IL 60120 0 1 0 4231783B IL 2026 REAR
9
IL A 7 1GCCS1445X8173244 PROGRESSIVE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 877742697 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 1 2 / F 2 3 0 1 0
m
/ / #OCCS D
71
/ / UI 2 m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 5 08,22 /2026 04 09 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 30 15
N 1 3 0 0 CITATIONS ISSUED 0 PENDING + ) 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
-a ARREST NAME / / ❑PM '
o N 1 ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
,
05
r 2 ARREST NAME AM
1 r ❑❑PM 0 Unknown work zone type U1
n 7 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 10
1516-Mancera. Maria 302 - r r ❑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 INDICATE NORTH combination):or —I
itst
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
-Ti - } (example:shuttle or charter bus):or
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I- I- -- Mille%I I I I I halt 1 I I I I } } } transporting employees the course passengers
employment operatedample:employee
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transporter-usually a van type vehicle or passenger car):or
C
L I. 4. Is used or designated to transport between 9 and 15 passengers,including N
}--- } } } g Po ssen rs,indudi the driver,
• for direct compensation(example:large van used for specific purpose):or
L ' ---i unit 2 - t } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
—I
CARRIER NAME Z
0 ADDRESS 0
w
Not To Scale I CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
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?
❑ 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
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
Gray Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE