HomeMy WebLinkAbout2026-00053110 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 61O72
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-0005311 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 �1
® ❑ RELATED ®Y 0 N 09 01 2026 DAM ❑YES ®NO U1
N CHANNING ST Elgin 03:52
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W NORTH ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FROra r TOWED U1 Q
FOR DAMAGED AREA(S)
NAME(LAST,FIRST,M) Munoz.Xavier.A. mo Volkswagen Atlas 2026 00-NONE 0: Qi_, DUE roCRASH ® 0
13-UNDER CARRIAGE } FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 0 m
M 2 6 ❑Y ®SNEM❑UNK VEH. O AT CRASH IN ENGAGEO 99-UUNKNOWN 016-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 �i COM VEH 0 j$J 1 0
" �- STREAMWOOD IL 60107 0 1 0 FIRST CONTACT 11 7 : --s *II Yes.See Sidebar u1
Z G H 27760 I L 2027 E
TELEPHONE
IL D 0 1V2KC2CA6TC234810 Arch Insurance Ely ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Elgin Fire VW Credit INC 41CAB1092102 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 c
x DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uv 0 KCV 0 Dv
'1 9 yr 0 Ford F150 2014 00-NONE 11_"I or-0 DUE TO CRASH 0 2
.ia13-UNDER CARRIAGE FIRE ❑ El U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y El N El UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI 6 i_i, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _6 •(ryes,See Sidebar
= ELGINREAR
IL 0 1 FTFW1 ET7EFB58132 Allstate ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire Same 866229321 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER
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 ❑Y U2 Z
N 1 ® 11 4 09,01 /2026 03 52 ®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 C)
v 2 0 2 99 09,01 ,2026 04 01 RI PM ❑Construction >F
R 3 0 xi CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
au ® 11 4 ARREST NAME Munoz.Xavier.A. 11-901-A 1500000411 09/01 /2026 04 04 lgi pM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
AM
r 2 El ARREST NAME 09/01 /2026 04 31 ®PM 0 Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1500-Chew. Marie 301 10 ,20,2026 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
r weightrating more than10,000 pounds(example:truck or truck trailer
1. Has i
` ` -' -' 0 r INDICATE NORTH combination):or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or
I Not To Scale
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
-- - . - . transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.__-a__ / u�2 - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
for direct compensation(example:large van used for specific purpose):or O
L L.._-a____. t i. < i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
m
15t - I I I placarding(example:placards will be displayed on the vehicle). XI
ICARRIER NAME Z
ADDRESS 0
I
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
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
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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 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE