HomeMy WebLinkAbout2026-00052351 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III 11 III1II IIIIII U
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00052351 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
1643 MULBERRY CT Elgin02:57
® ❑ RELATED 0 Y ®N 08 29 2026 ®AM ❑YES ®NO U1 -<
_ _ PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT,MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD IN STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EDUES 0 Nuv 0 ICU 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 3 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 9 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s l 6 1, COM VEH 0 0 1 C)
4
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 7 t .; --5 *II Yes.See Sidebar U1 0
Z G F12830 I L 2027 REAR
TELEPHONE
IL D 0 1ZVBP8EM005203375 American Alliance ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILAA117091300 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER
ou
0 DRIVER N. PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 M/V 0 NCV 0 Dv
yr Dodge Avenger 2013 00-NONE 1("j 12..-_, DUE TO CRASH ❑ ® 1 73
o 13-UNDER CARRIAGE 10'I c. 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16
❑ -TOP 3 9 0 X
a Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0is/rec os Value
POINT OF s 4Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR6 �' COM VEH D ® CO
F,,, FIRST CONTACT 5 7-:1_,SOS •If Yes.See Sidebar
EG60835 IL 2026 I0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 C3CDZAB4DN518454 Allstate ❑V ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
99 9 Ortiz.Anahi 866583484 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 co
08,29 ,2026 09 18 ®❑PM AM in a Work Zone? ®N DIRP D
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
5 2 ❑ 30 99 / / ❑PM ❑Construction *
Z3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
a1 ® 11 1 5 ARREST NAME Arizaga Baeza.Alberto 11-404 1530000855 , r El PM SLMT
o N •
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
15
r 2 ❑ ARREST NAME AM
1 r ❑❑PM ❑7Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 981 275-Engelke 10 ,05,2026 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
e ADDITIONAL UNITS FORMS.
r -- r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Scale TO Not1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }____r__--; I } combination):or —I
, INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
i_ •:. N AiN 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I. } } transporting employees In the course of their employment(example:employee73
transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 0 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
} } 1. •
for direct compensation(example:lar a van used for specific purpose): 0
, � G Pe 9 Pe or
L i...__a-___� i,Q 'f7 i. < i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
— e placarding(example:placards will be displayed on the vehicle). XI
-1
Unit 2 CARRIER NAME Z
._ ADDRESS 0
1643 D
Mulberry?Ct CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
• 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
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Black Red
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE