HomeMy WebLinkAbout2026-00052381 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 II I flfl IIH I 1111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�?35."•O$6
u, 1 U21 3 4 1 U1 3 U2 1 U, 1 1_12 1 U1 1 U2 1 1 15 u1 1 u2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00052381 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
KI M BALL ST El In 01:14
® ❑ RELATED ®Y 0 N 08 29 2026 12,— ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 7 /
yr 13-UNDER CARRIAGE 10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 4 rn
F 2 4 SYTM❑Y EIS NE
❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 76•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI a �i 4 COM VEH 0 14 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7 ;- -_5 *II Yes.See Sidebar U1
ZEL58465 IL 2026
TELEPHONE
IL D 0 1 GKKRTED1 BJ337919 StateFarm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 2849353-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 iiuv 0 i v 0 Dv
Yr
/2 0 0 4 Chevrolet Cruze 2016 00-NONE 'o,� t2 (,-2 FIRE DUE D CRASH D U2 2 C
o 13-UNDER CARRIAGE
c
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraelion Value 0 CON CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si S lt4 COM VEH ❑ ® U1
FIRST CONTACT 5 7 __,tv •It Yes.See Sidebar
ELGIN IL 60120 0 1 0 EL58465 IL 2026
IL D 0 1 G1 PE5SB8G7213980 StateFarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same J778141-C10-15 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 3 07 /
:A
/ / U1 1 D
/ / 3 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 08/29 /2026 01 14 ®AM 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 25 99 08/29 /2026 O1 40 ®pM El Construction
>F
R 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
a1 ® 11 4 ARREST NAME De La Paz. Bertha.A. 11-305 455-467 08/29/2026 01 44 igi pM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
t 2 ElARREST NAME / / ❑❑pM ElUnknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30
455-Hallac.Gabriel 101 09 / 15/2026 09 00 ❑P Workers present?M I 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
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ (example:shuttle or charter bus):or
X
< <----------; I - transportingtlgemployees lloyeeo slin the course of 5 or fewer passengers
e ersnanodyment example:employee a contract der
i eb last "" } F } transporter-usuallya van vehicle or type passenger car):or CO
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L - - - - l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
E ( -�_.�I.. + placarding(example:placards will be displayed on the vehicle). m
T� A
t EI --
I fl.;.. PI
,T CARRIER NAME Z
unmzl - -- ADDRESS D
+ i
: i'. .:r; ,
cITY�sraTErzlP n
Not To Scale MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
0 Yes 0 No ❑ Unknown 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 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Maroon
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE