HomeMy WebLinkAbout2026-00055146 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 10110111 flfl Ill lUU11111111ODU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO0 ,377745
u, 9 U2 1 1 1 u116 U2 1 U199 u2 1 u, 1 U2 1 5 9 u, 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00055146 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 rn
465 DUNDEE AVE Elgin07:24
® ❑ RELATED ❑Y ®N 09 10 2026 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ''Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED D DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
/ ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
Unknown.O. Nissan Rogue 2008 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 O <
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 t6.TOP 3 ❑ _
❑Y ®N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL e i COM VEH 0 j$J 1 0
I— 0 9 0 FIRST CONTACT 1 7_; __5 *lIVes.See Sidebar Ut
Z DF21581 IL 2026 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
JN8AS58V98W137463 Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Bustamante Maldonado. Idania Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
0 DRIVER I} PARKEo 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr 10 1 t2 c 2 FIRE ❑ ® U2 C
Ti 13-UNDER CARRIAGE
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 0 ® SPDR n
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraci n Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 11 1;.,_
COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 7 O7 S _s •IfYes See Sidebar
DX25725 IL REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2G N FLN E53C6162923 First Chicago Insurance C ®Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Mendoza-Becerra. Eva ILV83760304 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 09,10 /2026 07 24 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 28 99
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING 1 1 ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ID PM '
o N 1 ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
15
t 2 0 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 15
1545-VanEycke. Brier 301 r ! 0 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
1 Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
1.
-<
r -----i-----; Not To Scale I - INDICATE NORTH nation):or A
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
A A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
9 } } } transporting employees In the course of their employment(example:employee
tf. r ,�} transporter usuallyvanvehiclepassengercor drive
jjj / nspo - a type or car): �
__ __ j , / / / fo di ectc or peni mend tx tmpl rt betvan u 9 and 15 ge rg y/ /!/ } } } g po passen rs,includi the r,
r for direct compensation(example:large van used for specific purpose):or O
L i.____a____� _ � } } } ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
.13
placarding(example:placards will be displayed on the vehicle). XI
—I
CARRIER NAME i- i- .i. -I. — r . ._ L. 1..
ADDRESS Z
'Z
V)
0
50:
CITY/STATE/ZIP
MOTOR CARR.ID ❑ Ita ❑
I I T I ❑ Notnters in Cotemm./Gout. Not inIntrastate Comm./Other
-"--- ----- - USDOT NO. ILCC NO. rn
PCI
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
Red Silver
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE