HomeMy WebLinkAbout2026-00060003 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO0439 291
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00060003 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m
N RANDALL RD EIIn
® ❑ RELATED ®Y 0 N 10 02 2026 09:29 12,— ❑YES ®NO U1
_ _ g PRIVATE mo r day!yr ®PM FLOW CONDITION m
FT!MI N E S W ROYAL BLVD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
TREJO. DANIEL 0 7 /
yr 13-UNDER CARRIAGE 10 i ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<n
M 2 SY4 ❑Y ®SNE El LINK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 76•TDP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a 4 COM VEH 0 0 1 O
F. FIRST CONTACT 12 7 .— _5 *Irves.See Sidebar U1
Z SOUTH BELOIT IL 61080 0 1 0 AY50893 IL 2026
TELEPHONE
IL D 0 2HGFG3B57CH517958 PROGRESSIVE El ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 875819547 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 KNEE 0 NIA/ 0 i v ❑DV
1 yr 9 8 1 Subaru Forrester 2018 00-NONE 'o,� t2 (,-2 FIRE DUE ocRASH ® U2 2 C
o mo 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑YNi N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraelion Value 9 0
POINT OF s i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5
FIRST CONTACT 6 O7 ,�_QI OS •it Yes See Sidebar C
GILBERTS IL 60136 0 1 0 X110126 IL 2027 aR 0 N
IL D 0 J F2SJAGCOJ H599336 WEST BEND ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same H H D570699817 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 ❑Y U2 Z
N 1 ® 11 1 10,02 r2026 09 29 ®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
0 2 ❑ 28 03 1 1 ❑PM ❑Construction >E
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
- U2
a, ARREST NAME TREJO. DANIEL 11-601 1579000102 1 r ❑❑PM ❑Maintenance SLMT® 1 1 1 0 CITATIONS ISSUED PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
r 2 0 ARREST NAME 1 01 02 12026 09 40 ®PM 0 Unknown work zone type U1 El AM H 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1 579-Payleitner. Madison 901 10 , 19,2026 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••--, , i
IA 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 -<
i- ;.__-_r_-_-; combination):or
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ ; N - (example:shuttle or charter bus):or C)
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
Randall 11
INOT to - ' I. } } transporting employee in the course of their employment(example:employee X
Hanrrt7BlBa -- - i i i i transporter-usually a van type vehicle or passenger car):or CO
.- toNoo I1. 1: } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
Randall for direct compensation(example:large van used for specific purpose):or O
____a....� �rr - i. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
:l te -1
CARRIER NAME Z
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�� jN1
ROyl7alvd ADDRESS0n CITY/STATE/ZIP g
-I MOTOR CARR.ID ❑ Interstate ❑ Intrastate
> O
I I T I ❑ Not in Comm./Govl. Not in Comm./Other0
.----Y----, — _
E USDOT NO. ILCC NO. m
Source of above z
. If Yes,Name on placard 0
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
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
Silver Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE