HomeMy WebLinkAbout2026-00052635 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
IIIIII II II 1111111111010111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X61829
u, 1 U21 3 4 1 U1 8 U2 1 U, 1 1_12 1 1.11 1 U2 1 1 12 u, 1 u2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00052635 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mE CHICAGO ST EIIn
® ❑ RELATED ®Y 0 N 08 30 2026 03:32 DAM ❑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 ICIy #OF MOTOR 0 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
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 13 n
0 5 !
yr
13-UNDER CARRIAGE FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 III U2 13 r<r1
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 �i COM VEH El Ea 1 0
F. FIRST CONTACT 1 7 --. _;__5 *II Yes.See Sidebar U1
Z Carpentersville IL 60110 0 1 0 DQ86725 IL 2027 Is
TELEPHONE
IL D 0 2FMPK3J95JBB32111 State Farm ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 3637062-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y ® N 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 MAV 0 e v 0 DV
!1 9 9 7 Jeep(after 196��rokee 2019 00-NONE 11 12` t2 "_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE o 1 l 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 15-OTHER 016•TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN )�I *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 O NT OF 7 �_.OS CIOMs gee SH idebar❑ ® U1 CO
= Sleepy Hollow IL 60118 0 1 0 BY53116 IL 2027 I 0
Z
IL D 0 1 C4PJ LLB6KD316539 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 877191230 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 4 08,30 l2026 03 32 ®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
o"
2 20 99 1 1 ❑PM ❑Construction *
Z 3 ❑ Igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Rodriguez.Saul. E. 11-709-A S152700044 ! ! El PM SLMT
o Nu 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
0 AM
t 2 El ARREST NAME 08/30 12026 03 40 ®PM El Unknown work zone type U1 3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1527-Juarez.Jorge 1o1 388-Nelis 09 ,22,2026 01 30 ®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 ® f combination):orratingmore than pound (example:truck or truck/trailer
1. Has a weight 10 000 5 -<
u INDICATE NORTH tion): -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
4 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
- }} } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
' } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
a r for direct compensation(example:large van used for specific purpose):or O
< <____a____. E,M. u O... - i. L I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
ti" placarding(example:placards will be displayed on the vehicle).
V '75_ram D
j l0 exirwvai - CARRIER NAME
ADDRESS D
0 .pi. i. i. n
4.
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; 0 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Maroon
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE