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HomeMy WebLinkAbout2026-00050390 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 II I OH IIH U lll 111111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO04351346 u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 u, 1 U2 1 4 15 u1 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 202612026-00050390 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 08 20 2026 ❑AM ❑YES ®NO U1 -< SUMMIT ST Elgin 08:09 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 3 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 10 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 4 SYTM • ❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 16•TDP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1 ZGA99791 IL 2027 REAR TELEPHONE IL D 0 6G2ER57749L165564 None ❑Y 0 N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same None 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER • RESPONDER > Refused 0 Y ❑ N 2 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiAV 0 Ncv 0 DV CIRCLE NUMBER(S) U1 !1 9 5 0 General MotorSiQoEp 2014 00-NONE ,01112 ;,-2 DUE TO CRASH 0 D U2 2 C .. 13-UNDER CARRIAGE III c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9;1,6•TOPO3 * X 0 Y NJ 0 UNK VEH. AT CRASH 99-UNKNOWN 0istraclIon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S- l 6• ( 4 COM VEH ❑ ® U1 W FIRST CONTACT 2 7- _, _5 •)ryes.See Sidebar = ELGIN IL 60123 0 1 0 1591762B IL 2027 REAR C • M IL D 0 3GTU2VEC8EG503032 Farmers ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 195661075 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPOND O N u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 3 1 0 / UI 1 D / / 2 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 81 /01 /026 08 10 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM •U1 C) , 2 0 23 15 81 !01 /026 08 10 ®PM ❑Construction F R o xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ❑AM ❑Maintenance U2 o 1 ® 11 1 ARREST NAME Montoya.Juan 11-1204-B 476000469 81 /01 /026 08 12 Igi PM SLMT I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME p N AM• ❑Utility 30 r 2 ElARREST NAME Montoya.Juan 3-707 476000470 81 !01 /026 09 06 ® , PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 476-Ramos.Clarissa 102 - / / ❑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 i•____r____; _ 1 Has weigon):ht rating more than0,000pounds(example:truckortruckrtrailer 1. � 0 INDICATE NORTH unei BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - } (example:shuttle or charter bus):or X i i i iji II 3. Is designed to carry15 or fewer passengers and operated a contract carrier O } r } transporting employee In the course of their employment(example:employee 73 4 transporter-usually a van type vehicle or passenger car):or w i. -----}----; - • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C s xrar for direct compensation(example:large van used for specific purpose):or O L L____a____. urs — — L 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). XI 1 r —1 CARRIER NAME Z 'n V) A CITY/STATDDRESS EJZIP gn - i. i. i. MOTOR CARR.ID ❑ Interstate ElIntrastate Ii.Not To Scale I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 --- --1 - USDOT NO. ILCC NO. m XI Source of above z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes ❑ 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 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 Blue Blue.Light u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE