HomeMy WebLinkAbout2026-00055512 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0�76470`
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00055512 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ❑Y ®N 09 12 2026 ❑AM ❑YES ®NO U1 -<
N LIBERTY ST Elgin12:16
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
1 O !MI N E S W Page Ave COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 1 fA
® g Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 NCV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FOR DAMAGED AREA(S) FROM TOWED U1 O
NAME(LAST,FIRST,M) Rubio. Miguel.A. 0 mo 4 /
/1 9 9 7 Dodge Ram 1500(pickup) 2022 00-NONE ,,, 12 DUE TO CRASH 0 13-UNDER CARRIAGE 101 ! 2 7.1 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 3 <<T1
M 2 4 SYTM IN ENGAGE❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S i�6 �i 4 COM VEH 0 j$J 1 O
H 1- ELGIN I L 60120 0 1 0 3509925b I L FIRST CONTACT 1 7_; __s *If Yes.See Sidebar U1
Z E
TELEPHONE
IL 0 1 C6SRFFT1 NN362889 All State ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Naranjo. Karla.S. 969652299 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NW 0 u v 0 Dv
!1 9 5 0 Chevrolet Malibu 2013 Do-NONE ,t_ 12 _, DUE TO CRASH ❑ 21 2 73
0 13-UNDER CARRIAGE 1a 1 z FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016.70P 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0.. 6 i'._4 COM VEH ❑ ® ut CO
FIRST CONTACT 9 7 _, -5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 EWG887 IL 2027 I Si)0
IL D 0 1 G 11 B5SA9DF336274 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Schultz.Sharon. L. 4114618-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 08 /
U2 2 Z
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
N 1 ® 11 1 09/12 /2026 12 16 ®PM in a Work Zone? ®N DIRP co
1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 .,
0
2 ❑ 20 99 / / ❑PM ❑Construction
Z 3 ❑ xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Rubio. Miguel.A. 11-709-A 1575000056 / / El PM SLMT
S' N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
0 AM
t 2 El ARREST NAME 09/12 /2026 12 16 ®PM 0 Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1575-Williamson.Colin 201 10 /06/2026 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
I ADDITIONAL UNITS FORMS.
/ A CMV is defined as any motor vehicle used to transport passengers or property and: Z Y .. � /
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
r combination):or —I
INDICATE NORTH p1
r�ro i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. - - _ } (example:shuttle or charter bus):or
X
I- I- --I--•--; / transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employeener X
® / transporter-usually a van type vehicle or passenger car):or C
L I- --I--. / } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, y
....--
---.-----..-1/ for direct compensation(example:large van used for specific purpose):or O
s t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
•U
placarding(example:placards will be displayed on the vehicle). XI
. 1
CARRIER NAME Z
ADDRESS 'n
C)
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I r ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
Y : : USDOT NO. ILCC NO. T.
m
73
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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
Tan
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE