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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 8
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00008201 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
BIG TIMBER RD El In09:29
® ❑ RELATED ®Y 0 N 02 11 2026 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FTlMI N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 5 !
yr 13-UNDER CARRIAGE 10 • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SY 15-OTHER
8 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�S �i 4 COM VEH 0 j$J 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar U1
Z EY76119 IL 2026 E
TELEPHONE
IL D 0 5J8TC2H6XNL001544 State Farm ❑Y Igl N U2 11 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3545237SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW 0 NOV ❑DV
!2 0 0 0 Jeep(after 1986,}eerty 2015 00-NONE 0. Q!'-O DUE TO CRASH rg ❑ 2
o 13-UNDER CARRIAGE 10( I 2 FIRE 0 El U2 C
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraelion Value 9 0
i1i N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 8 7 B 4 COM VEH ❑ ®
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Z REARIfYes,See Sidebar U1 CO
Cary IL 60013 0 1 0 TKK5092 TX 2026 0 N
D
IL D 0 1 C4PJ LCS5FW707515 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Roman. Daniela I LAA113788100 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (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 0 Y U2 Z
N 1 ® 11 4 02,11 l2026 09 31 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 6 C1
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0 2 ❑ 25 2 ) ! ❑PM ❑Construction X
4
Z 3 ❑ Igi CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Hernandez.Joshua.A. 11-305-A 1540-438 / ! ID PM SLMT
o N
u 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
0 AM
t 2 El ARREST NAME 02/11 12026 10 10 0 PM El Unknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
366-Greer.Adam 500 337-Thompson 04 ,06,2026 01 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 -<
c ` ''- ' r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15C
g sp passengers including the driver 0
i_ _ i (example:shuttle or charter bus):or
I I L Not To Scale ] r p ) X
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 X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ - - - - - 4. Is used ordesi natedtotrans rtbetween 9 and 15 passengers,including C} } } g ( p transport gfcepurpose):
n �e)or the dryer,
eyvme.nrte. for direct compensation(example:large van used for specific ur
O
__ UnM= ; i.- t 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). XI
CARRIER NAME Z
ADDRESS 'n
D1 * . , ... ,.........
1 ' i
0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
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
Black 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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE