HomeMy WebLinkAbout2026-00059751 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X O3990
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00059751 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
VILLA ST Elgin 05:51
® ❑ RELATED ®Y ❑N 10 01 2026 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W S GIFFORD FFORD ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O C)
0 8 / yr
Rodriguez Morales.Osbalda Hyundai Tucson 2017 00-NONE 0''_
s O DUE TO CRASH ® ❑
13-UNDER CARRIAGE ,I o'.: FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El ]$I U2 tz
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3 (<Tl
F 2 4 ❑Y ®SYSNEM❑UNK VEH. O AT CRASH 0 99-UUTHER NKNOWN 9 16•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 �i 4 COM VEH ❑ j$J 1 0
'° ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 11 7_;1 __5 •lIYes.See Sidebar U1
Z EG86809 IL 2026 ' E
TELEPHONE
IL D 0 KM8J3CA46HU433742 AMERICAN ALLIANCE ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Elgin Fire Same I LAA 1185066 00 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2
m N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NCV ❑Dv
yr 12
o 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C
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F 2 5SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16_TOPO3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistracuon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i 6 I,_.4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 2 Y��_, _5 •)ryes.See Sidebar C
ELGIN IL 60120 B 1 0 EF85778 IL 2026 I Si)0
IL D 0 JA32U8FW5EU002249 FALCON INSURANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 01 001 1 6035-1 0 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
St.Alexius Medical Center RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI j(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 4 05 /
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/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 10/ 11 /026 05 51 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
v 2 ❑ 28 2 10(11 /026 05 57 ®PM El Construction
>F
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Rodriguez Morales.Osbalda 11-601 1556-000215 10/11 /026 06 00 Igi PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM
t 2 El ARREST NAME 10/11 /026 06 41 ®PM ElUnknown work zone type U1 15
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1556-Sanchez.Jimena 1o1 356-Sostre 11 / 31 /026 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 truck trailer -<
i- }--_.r-_--; INDICATE NORTH N combination):or —I
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L_+_J 1
' r r (example:shuttle or charter bus):or
1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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` 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
,�^ transporter-usually a van type vehicle or passenger car):or co
L L.___a____� .�` 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y
u - } } for direct compensation(examp::large van used for speific purpoe):othe driver,
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L L----a-- I O ��' - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
4�_ ua2 .., placarding(example:placards will be displayed on the vehicle). XI
o CARRIER NAME Z
Not TO SCaIe ADDRESS D
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CITY/STATE/ZIP Og
MOTOR CARR.ID 0 Interstate El Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; USDOT NO. ILCC NO. m
XI
Source of above z
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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
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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 White
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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE