HomeMy WebLinkAbout2026-00051735 ILLINOIS TRAFFIC CRASH REPORT sheet 1 a Sheets 01111101111 0110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 631
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00051735 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN STATE ST Elgin10:15
® ❑ RELATED ' ' 0 N 08 26 2026 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W WING ST COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR IR SLOW 15 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
0 DRIVER ❑ PARKED IN DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0!CO 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
! ! FOR DAMAGEDAREA(S) FRO Ni TOWED U1 Q
Unknown. Unknown. U. Subaru Outback 2006 00-NONE it.. 12 , DUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
fa !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 4 <
M 9 4 SYSTEM IN O ENGAGED 0 15-OTHER 9 76.TOP 3 ❑ _
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN $ 4 `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iII a ii COM VEH 0 181 2 O
Z0 1 0 EN53853 IL FIRST CONTACT 6 r:LQ-_s Yes.See Sidebar U1 0
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2
4S4BP61C867341965 unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Dominguez-Rodriguez. Dolores unknwon 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 My 0 Ncv 0 Dv
!1 9 5 8 Nissan Kicks 2025 00-NONE 11_j el,-_( DUE CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10( l FIRE 0 ® U2 C
Ti
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7� ems •(ryes.See Sidebar
Z ELGIN IL 60123 0 1 0 1001TM IL REAR C
0 cn
IL 7 3N8AP6CB1 SL432252 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 967957340 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (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 0 Y U2 Z
N 1 ® 11 1 08/26 /2026 10 15 ®PM 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 �
57 2 ❑ 10 17
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING ( 1 ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ❑PM '
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
AM30
Ti 2 ❑ ( r ❑❑PM ❑Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ — ❑AM Workers present? ❑Y 30
1519-Bae2 a.Guadalupe 501 ( / ❑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 .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ® - } r r ,. (example:shuttle or charter bus):or 0
A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
Not 7b Scale J } } } 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__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
I I � Pe ( P 9 Pe or O
L L--_-a-___.I €i - t 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). ,Zmt
I I- --
(" CARRIER NAME Z
1 __ 1 ADDRESS 0
w
Mro+s 1 i I i N.,amrr9[ CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
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. w
Blue,Dark Red
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