HomeMy WebLinkAbout2026-00002161 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11I1 UHU II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X141969
u1 9 U2 1 1 1 U1 9 U2 U1 99 U2 U1 99 U2 1 4 9 U1 23 U221 *P 0119*
1
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 ❑$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2O26I 2026-00002161 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1
® ❑ RELATED ' V 0 N 01 12 2026 ®AM ❑YES ®NO U1 —<
S UNION ST Elgin06:00
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W UNION CT COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR El SLOW 15 Co
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O n
/ / FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y 0 N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 0
~ 0 9 0 FIRST CONTACT 99 7_; _5 *If Yes,See Sidebar U1
REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
unknown ®Y 0 N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N0 N
W p DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m/V 0 i v 0 DV
yr 13-UNDER CARRIAGE FIRE ID El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED
a SYSTEM IN 9 ENGAGED 9 15-OTHER 016-TOP 3 0 ® SPDR n
❑Y ❑N I UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0/�iII _ I; 4 COM VEH 0 ® U1 CO
F„ FIRST CONTACT 11 (LA 1_t°( .9 •IfYes.See Sidebar C
H144685 IL 2026 REAR0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
JTMZD33V285108591 Horace Mann ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
FAUSTO. RODOLFO. E. 65000230210103 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 01 J 12 l2026 06 24 ®❑pmn in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
Ei 2 ❑ 30 28
N 3 ❑ ❑CITATIONS ISSUED ID PENDING + ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME ! ! ID PM '
S' N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
r 2 ❑ 25
ARREST NAMEAM
7 1 / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
410-DeLeon.Jessica 701 — r 1 ❑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
�____r____; I - combination):. Hasor more than pound (example:truckortrucktrailer 1. Has a weight rating10 000 5
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
i S?Unlon?', - } (example:shuttle or charter bus):or 0
A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
i
} } } transporting employees in the course of their employment(example:employee
rter-
y a van type
L L.___a____� N f 4alsuosedord�llnatedto transport betweeicle or n9 and r15r) ssen rs,indudirg[hedriver, to
union?Ct _ f a } } } for direct compensation(examp large van used for specific purpose):or O
` `----A----i _ �nk 1 t i t E - _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
_ placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
I - ADDRESS 0
Not To Scale D
rn
I
CITY/STATE/ZIP C
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. Not in Comm./Other
I ‘I.
I I
,....Y___. ' USDOT NO. ILCC NO. m
XI
Source of above z
. xi
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 ❑ No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue.Light
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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