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HomeMy WebLinkAbout2026-00052612 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 II I flfl 1111111100110000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 63205 u, 1 U21 3 4 8 U, 3 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash 0 AMENDED YR 202612026-00052612 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 7 BLUFF CITY BLVD EIIn ® ❑ RELATED ®Y 0 N 08 30 2026 01:01 12,— ❑YES N NO U1 _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 3 Cl) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 1 2 / yr 13-UNDER CARRIAGE ©,I �::0 FIRE ❑ al E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 0 171 F 2 4 SYTM❑Y NSNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TDP 3 `Distraction Value 7 ALGN = V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 4 COM VEH 0 1� 1 0 I . HuntleyIL 60142 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.SeeSidebar U1 Z EP43736 IL 2027 REAR TELEPHONE IL D 0 1 HGCR2F54HA301735 State Farm ❑Y Il N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 3687901-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv !1 9 8 6 Dodge Caravan(inc Grand)2002 00-NONE 11"1 0iNT.•O DUE TO CRASH rg ❑ 2 x 13-UNDER CARRIAGE I FIRE ❑ N U2 M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16"TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i 6 i.!., COM VEH ❑ N U1 CO FIRST CONTACT 1 7 _, _5 O. )ryes.See Sidebar C ELGIN IL 60120 0 1 0 GC27105 IL 2227 Si)0 MX A 9 1 B4GP44382B609606 Safeway Insurance ❑Y N N RDEF Xl EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Gomez Sanchez. Martin 4367157-IL-PP-001 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS))(TELEPHONE) (EMS) (HOSPITAL) 1 1 1 1 / / / UI 2 :A D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 08,30 l2026 01 01 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 ❑ 28 25 / / ❑PM ❑Construction >E Z ' EMS ARRIVED TIME 1 3 ❑ CITATIONS ISSUED 0PENDING SECTION CITATION NO. ❑AM ❑Maintenance U2 -a, ARREST NAME Raya.Yulia 11-601 S1542-001008 / / ❑PM i u 1 N 11 4 �(CITATIONS ISSUED 0 PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME AM' ❑ 30 T 2 El ARREST NAME Raya.Yulia 11-306 S1542-001009 08/30 /2026 01 45 N PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1542-Chase. Ethan 401 09 , 15/2026 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 e-----e••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Has a weicombination):ght ratinor g more than 10,000 pounds(example:truck or truckrtrailer -< INDICATE NORTH - Not To Scafe BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n _ } (example:shuttle or charter bus):or X L A } 3. Is designed to carry 15 or fewer passengers and operated 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 _a__. 4 } } 1" 4. Is used or designated to transport between 9 and 15 passengers,including the driver. y I F for direct compensation(example:large van used for specific purpose):or L L____a____- �` \ \ ` =I I , - L i. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 1 O .D -- placarding(example:placards will be displayed on the vehicle). m 21 1 - — - —I "� CARRIER NAME Z i O = =`' - -- ADDRESS V) CICITY/STATE/ZIPC) MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I 44 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 ----- ----1 - USDOT NO. ILCC NO. C m 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 0 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 White Silver 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE