HomeMy WebLinkAbout2026-00059870 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00439 304
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00059870 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 mKI M BALL ST I GROVE AVE EIin09:44
® ❑ RELATED ®Y 0 N 10 02 2026 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
15 !MI N E S W kimball stl rOVe ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
® ® 0g Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS O
DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FR
Rodriguez.Arlette Honda Civic 2010 00-NONE
13-UNDER CARRIAGE „ 12m4r TOWED U1 Q
NAME{LAST,FIRST,M) g mo yr EN
, DUE TO CRASH ❑
101 ! FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 0 m
F 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 016-TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� 6 �'.4 COM VEH 0 j$J 1 n
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 8 O_; __5 *If Yes.See Sidebar U1 0
Z GJ17279 IL 2027 E
TELEPHONE
IL D 0 2HGFG1 B64AH535568 Farmers Insurance ❑Y ®N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Rodriguez.Jose. D. 516397886 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
yr ��I t2 ( E FIRE ❑ Ej U2 C
o 13-UNDER CARRIAGE
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistracti n Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 j( 4 COM VEH ❑ ® U1 W
FIRST CONTACT 2 7-'_, _5 •(ryes,See Sidebar
= ELGIN IL 60120 0 1 0 GD14920 IL 2027REAR
D
CA D 0 3MW69FTOXT8G58334 Sate Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Soriano. Bello 3973520-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,03 ,2026 09 44 ®❑pM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
T
o"
2 0 06 2 / 1 ❑PM ❑Construction X
7
Z 3 0 lyg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
aEl 11 1 ARREST NAME Rodriguez.Arlette 11-801 1540-W568 t r El PM 0 Utility SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
AM 30
t 2 0 ARREST NAME 10 i 03 12026 10 45 MPM 0 Unknown work zone type U,
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1540-Allah. Muhammad 102 , ❑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.
Orove?Ave
r ----r••--, , , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
INDICATE NORTH
BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driver
C
I - (example:shuttle or charter bus):or 0
I 3. Is designed tocarry15 fewer passengers and operated a contract carrier O
eS or
- } } } transporting employees in the course of their employment(example:employee X
1 OP transporter-usually a van type vehicle or passenger car):or w
L L.___a____� am } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
I -0: } } for direct compensation(example:large van used for speific purose):or
-Unit 2— L } L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
Unit 2 placarding(example:placards will be displayed on the vehicle).
Klmball?9t
_7
CARRIER NAME Z
I -
ADDRESS 0I IC
I Not To Scale I CITY/STATE/ZIP g
I i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I -- I I ❑ Not in Comm./Govt. Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ❑ No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No ❑ Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
El Yes 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 ❑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
Gray Gray
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