HomeMy WebLinkAbout2026-00002301 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets lUI
III H
IIII
DIII
II II IIII I II IIIIIIIII IIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO04107980
u, 1 U21 2 4 1 u1 1 U2 2 u, 1 1_12 1 u, 1 U2 1 5 15 u1 1 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00002301 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
MAY ST El In 06:58
❑ ® RELATED ®Y 0 N 01 12 2026 12,— ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT!MI N E S W S LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 rary 0 NOV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 2 /
yr 13-UNDER CARRIAGE 16 1 EN
2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 rn
M 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 I,.4 COM VEH 0 0 1 0
F• Elgin I L 60120 B 1 0 FIRST CONTACT 12 7_: __5 *IIYes.See Sidebar U1
Z 9 DV36793 IL 2026 REAR
TELEPHONE
IL D 0 2GNALBEC6B1248245 STATE FARM ❑Y ®N U2 I''I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
rn
9 Same 3801971SFP13 1 17"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uv 0 NOV 0 Dv
Yr
'1 9 9 1 Lincoln Continental 2020' 00-NONE O, Q1-_, DUE TO CRASH ❑ 2
o 13-UNDER CARRIAGE 1 I FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s I 4 6 I COM VEH ❑ ® U1 CO
FIRST CONTACT 1 7�i1
. -5 •If Yes.See Sidebar
= West Chicago IL 60185 0 1 0 FS21353 IL 2026 I 0
IL D 0 1 LN6L9VK4L5601706 BRISTOL WEST ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same G01716420700 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB I (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 05 /
/ / UI 2 D:A
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
u 1 ® 11 1 01 /12 /2026 06 58 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
o"
2 ❑ 2 99 / / ❑PM• ❑Construction
4
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
—a, ARREST NAME Ordonez Hernandez. Eleazar, M. 11-1204-B 1535000266 / / El PM SLMT
oN 1 ® 11 1 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility
t 2 El ARREST NAME Ordonez Hernandez, Eleazar, M. 6-101 1535000265 01 1 12 /2026 06 58 ®PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1535-Solis, Laura 401 320-Cox 02 , 17,2025 01 30 El 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 -<
INDICATE NORTH p0
I L... 4 N— BY ARROW c2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
Not To so yJ 3. Is desgned to car 15 or fewer passengers and operated a contract carrier O
l- <_---------i l I
} } } transporting employees In the courseof thir employment(example:employee X
C
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including cci'-- -- - } } } g po passen rs,includi the driver,
;il=e},l for direct compensation(example:large van used for specific purpose):or O
L C.rts L i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Ili placarding(example:placards will be displayed on the vehicle). ;p
I . 1
I I CARRIER NAME Z
1 __ ADDRESS T.
0
CITY/STATE/ZIPMOTOR CARR.ID 0 Interstate El Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— ------1 - USDOT NO. ILCC NO. rn
73
Source of above z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. P3
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 0 No 0 Unknown M
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 VIM 1 m
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray 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 DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE