HomeMy WebLinkAbout2026-00054658 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 II I fl U
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1,500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00054658 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 '1
1029 N RANDALL RD Elgin02:00
® ❑ RELATED ❑y ®N 09 08 2026 DAM ❑YES El NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD IN STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME(LAST,FIRST.M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 0
I- 0 9 0 FIRST CONTACT 99 7_; _5 *lIYes,See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
d NA/ ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NIA 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99 G0)
m ❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 Ncv 0 DV
yr 10;j 12 c, E FIRE 0 ® U2 2 C
13-UNDER CARRIAGE
v AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
SEX SAFT AIR 9!19.Top * 0
SYSTEM IN ENGAGED 15-OTHER
a ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9
POINT OF 8 4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 j',_ COM VEH ❑ ® CO
FIRST CONTACT 3 7_ _,-_6 •• •IT Yes.See Sidebar
H 3358380B IL _aR 9 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3GCPDBEK6NG531702 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Figueroa. Luz. M. 1454461-sfp-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 09,08 /2026 03 09 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 15 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
z
—a, ARREST NAME / / ❑PM '
o u ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
10
T 2 0 ARREST NAME AM
7 , , ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 560-Martirez.Samantha 502 337-Thompson , , ❑❑PM Am Workers present? ®N U2 10
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
0 ADDITIONAL UNITS FORMS.
r ----r••--, , N' 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 -<
c ` -' -' r INDICATE NORTH combination):or A
iramtzztammairote BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or C)
X
L A _ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee P3
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,
Pe ( P 9 Pe or O
L i t i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
—1
CARRIER NAME Z
Untt 2
ADDRESS 0
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I ‘I.
_ ____.Y Not To Scale + USDOT NO. ILCC NO. m
73
Source of above z
. 0 Yes II No ❑ Unknown 0
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
4
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE