HomeMy WebLinkAbout2026-00001579 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004096613
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2O26I 2026-00001579 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
KATHLEEN DR Elgin
® ❑ RELATED ❑Y ®N 01 09 2026 ®AM El YES ®NO U1
PRIVATE mo /day/yr 06:37 ❑PM FLOW CONDITION m
�O ICJ ® COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
!MI N E SLilac Ln WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS O
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRO T TOWED U1
Hernandez Chic. Pedro 0 2 /
yr 13-UNDER CARRIAGE EN
O i FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 2 m
M 2 4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 016-TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
POINT OF D.:L 6 �L,4 COM VEH ❑ Zg! 4 0
~ E LG I N I L 60123 0 1 0 FIRST CONTACT 10 7_; __6 *II Yes.See Sidebar U1
Z EV23482 IL 2026 REAR
TELEPHONE
IL D 0 1 NXBR32EX5Z558121 First Chicago Ins Co ❑Y igi N U2 11 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same ILS1176746-01 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑Nuv 0 Ncv ❑Dv
$ /1 9 6$
^ NAME(LAST,FIRST,M) Camarillo Colin.Angelica Mazda MAZDAS 2012 Do-NONE N_. 12 "_, DUE TO CRASH ❑ C 2
0 13-UNDER CARRIAGE o I 2 FIRE ❑ El U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac)on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 O NT OF O`)] 6 L`_6 CIO es See SH idebar❑ ® UtIN
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H ELGIN IL 60123 0 1 0 BE33193 IL 2026 I 0 fn
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IL D 0 J M 1 CW2BLXC0112033 Kemper ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 12RA000044037 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,12 /26 06 38 ❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 20 05 ! ! 0 PM ❑Construction *
A
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 4
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Hernandez Chic. Pedro 11-709-A 495000479 / / El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
r 2 ❑ ARREST NAME AM
T ! / PM ❑Unknown work zone type 30
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME CIAM Workers present? ❑Y 30
495-Sjodir.Jacob 602 21 / 71 /026 01 30 ®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 combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver(example:shuttle or charter bus):or C C
12 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
< I- --I--
t } ,} } transporting employees in the course of their employment(example:employee
\ transporter-usually a van type vehicle or passenger car):or w
L }-----}----; - } 4. Is used or designated to transport between 9 and 1 passen rs,including the driver. C
N I for direct compensation(example:large van used fors specific purpose):or to
I. } }
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L L____a. � ' I _ L t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m
t placarding(example:placards will be displayed on the vehiclele).), ,Z
CARRIER NAME Z
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ADDRESS
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Not To Seale ' CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ 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
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ . 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