HomeMy WebLinkAbout2026-00011360 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004152140
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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 ❑5501-51,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00011360 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 02 27 2026 12,— ❑YES ®NO U1
LARKIN AVE Elgin mo /day/yr 02.01 ®PM FLOW CONDITION M
02040/MI NOS W North Jane Dr COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15
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
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
FOR DAMAGED AREA(S) Mao TOWED U1 Q
Alvaos.Jesus.A. 1 1 /
yr 13-UNDER CARRIAGEi FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTHER TAL(ALL) O 2 DISTRACTED 0 0 U2 04 M2326
UNK VEH. 0 ATCRASHD 0 99-UUNKNOWN O9 16•TOP 3 `DistractionValue 7 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a �i 4 COM VEH 0 El 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 9 7_: -_5 *II Yes.See Sidebar Ut
ZCL40669 IL 2026 REAR
TELEPHONE
IL D 0 2T1 BURHEXGC521292 Unique Insurance Company ❑v ®N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Segura.Gonzalo.A. ILP3397542 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lily 0 Ixv 0 CIRCLE NUMBER(S) U1
DV
/1 9 9 1 Tesla Y 2022 oo-NONE 11 ' 12 DUE TO CRASH 0 ® 98 x
o 13-UNDER CARRIAGE I FIRE ❑ ® U2
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6.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 i1 4 5 Lf,_ COM VEH ❑ ® U1 W
FIRST CONTACT 1 7�- -5 •
H Hampshire IL 60140 0 1 0 A8104EL IL 2026 REARIt Yes,See Sidebar 0 N
IL D 0 7SAYG DEF1 N F464820 Travelers ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Domingo.April 1 R571635TXS26 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
;UNIT) ISEATI (D08) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 4 09 /
UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 21 ,71 /026 02 02 ®PM 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
o"
2 20 99 , / ❑PM ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a1 ® 11 1 ARREST NAME Avalos.Jesus.A. 11-709-A S1569000006 / / ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
t 2 ❑ ARREST NAME AM
7 , / PM 0 Unknown work zone type 35
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1569-Jaimes.Julian 602 41 r 41 ,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
�____r____; N _ 1 Hasatgnig):htratingmorethan10,000pounds(example:truckortrucktrailer -<
1.
INDICATE NORTH -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
F, _ } (example:shuttle or charter bus):or 0
' Lwe J 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } } transporting employees In the course of their employment(example:employee X
f transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including cC/t
---- ----; f - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
D
L____a____. r _ L _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
tplacardig(example:placards will be isplayed on the vehicle). ,Zmt
r CARRIER NAME Z
ADDRESS 'n
D
CCITY/STATE/ZIPn<
nrorrosceb , <
_ i. i. MOTOR CARR.ID 0 Interstate El
l ❑ Not in Comm./Govt. ❑ Not in Comm./Other 4.
00
---'--1 - USDOT NO. ILCC NO. C
m
XI
Source of above 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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Red
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE