HomeMy WebLinkAbout2026-00058906 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED yR 202612026-00058906 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
N LIBERTY ST El 03:23
® ❑ RELATED 0 Y ®N 09 28 2026 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day!yr ❑PM FLOW CONDITION ITT
FT N E S W FREMONTST COUNTY PROPERTY ElY ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/
ftf FOR DAMAGEDAREA(S) FRO �TOWED U1 0
NAME(LAST,FIRST,M) Unknown.0. mo Mini Cooper 2006 00-NONE 1.,... Qz ,a:/ouE TO CRASH ® ❑ ' E
13-UNDER CARRIAGE 10 i , 2 FIRE 0 NIC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2
9 5 SYSTEM IN
Y O ENGAGED O 15-OTHER 9 16.TOP 3 0 _
❑ ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL 6 il,4 COM VEH ❑ Ea 1 0
~ 0 1 0 FIRST CONTACT 1 7_; __5 *uYes.See Sidebar U1
Z G B33898 I L 2027 ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED
WMWRC33516TJ79015 Unknown ❑v ❑N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Garcia. Heriberto Unknown 1 rn
`5 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
.5 RESPONDER 0
m ❑ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 N4y 0 KCV 0 Dv
yr 12 _ C1
o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 4 -
POINT OF s-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—d:=5 COM•I sVEH •Sidebar❑ ❑ C
CO
F` ---i- co See
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESP❑Y°❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
W 09 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ❑ 1 3 Elgin.City.o. Hit a utility pole. 09/28 ,2026 03 23 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 .,
;, 2 ® 43 3 150 DOUGLAS AVE ELGIN IL 60120 28 20
/ / 0 PM• ❑Construction >F
t
Z3 0 ❑CITATIONS ISSUED CIPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
a 7 ARREST NAME / / IDPM '
-
•
o N 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
t 2 0 ARREST NAME AM
! r ❑❑PM ❑Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. -SUPERVISOR ID. COURT DATE TIME y
2 3 ❑ ❑AM Workers present? ❑
1546 Ignacio. Patricia 202 ! 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
till .
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 -<
�____r____� Not To Scale combination):or
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
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or o
L i l. i m
5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
0
t . r „ , - , .1
b CARRIER NAME Z
ADDRESS 0
D
rn
n
CITY/STATE/ZIP g
il 3r MOTOR CARR.ID 0 Interstate 0 Intrastate
I I -I- •max r ❑ 0
I � Not in Comm./Govt. ❑ Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. C
m
73
Source of above z
. GVWR/GCWR m
0 <10,000 0 10,000-26,000 0 >26,000 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
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Green.Light
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWEDDUET DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE