HomeMy WebLinkAbout2026-00058478 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M 11111111IIIII I I I I I III I II
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X+ 92978
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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 2
VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) N B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00058478 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
GETZELMAN DR Elgin 08:26
® ❑ RELATED ®Y 0 N 09 25 2026 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr NPM FLOW CONDITION MFT!MI N E S W CLAYTON AVE COUNTY PROPERTY ❑Y N N DOORING ICIy #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
HERNANDEZ. MARIA 0 8 /
yr 13-UNDER CARRIAGE ta,l !�. 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 0 M
F 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TDP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i 4 COM VEH 0 N 1 0
ELGIN N I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1
ZDL44887 IL 2027 REAR
TELEPHONE
IL D 0 1 FM5K8D8XEGA16974 All State ❑v Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 969761420 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y N N 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
/1 9 9 3 Kia Motors Cot�oul 2014 00-NONE 'o.r t2 (,-2 FIREo CRASH ® U2 2 C
o Yr 13-UNDER CARRIAGE0
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TtOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraclion Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF G'i- 6 11:,_4 COM VEH 0 N U1 CO
C
FIRST CONTACT 7 QJ__,�_5 *It Yes.See Sidebar
Z Crystal Lake IL 60014 0 1 0 EW61739 IL 2027 I 0
Z
IL D 0 KN DJ P3A55E7725765 First Chicago ❑Y N N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same PAL 1207947-01 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 09 /
/ / UI 2 :A
D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 09/25 /2026 08 26 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 0 20 18 / / 0 PM ❑Construction >F
Z3 ❑ N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
a HERNANDEZ. MARIA 11-708 S1570-000297 / / PM
-, ® 11 4 ARREST NAME ❑
o u CITATIONS ISSUED PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
t 2 El ARREST NAME 09/25 /2026 09 25 N PM El Unknown work zone type U1 0 AM 25
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1570-Tomlin. Eli 500 10 / 13/2026 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
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 truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or —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
I- I- --I--•--; - transportingdgemned to ploaeesl5 or fewer In the course of passengers
e a mplanoyment example:employee a contract ner 73
} • employees employment
Not To Scele I a con ... transporter-usually a van Type vehicle or passenger car):or C
L "" N I.
} •4. Is used or designated to transport between 9 and 15 passengers,including the driver, (I)t II nn ""' ""' for direct compensation(example:large van used for specific purpose):or O
t n t 1 L i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
# %. .. ... .....
CARRIER NAME Z
ADDRESS '0
0 I dd C)
CITY/STATE/ZIP g
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
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
to
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
White Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
Arties SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO.TO ® Arties VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE—