HomeMy WebLinkAbout2026-00011907 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0011110 011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X{3041554,,0'
U1 1 U21 1 1 1 u, 2 U299 u, 1 U2 1 u,99 U2 99 1 10 u, 3 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00011907 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
S MCLEAN BLVD Elgin03:26
® ❑ RELATED ❑Y ®N 03 02 2026 ❑AM ❑YES El NO U1 -<
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W LILLIANST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 15 u)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 5 !
yr 13-UNDER CARRIAGE IE
101 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 rn
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASIN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i 4 COM VEH 0 Ea 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 1 7 . -_5 *II Yes.See Sidebar U1
Z AV68869 IL 2025
7 TELEPHONE
IL D 0 4T4BF1 FK3ER384038 State Farm ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0928742-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑MAV 0 KCv ❑DV
!1 9 8 9 Infiniti QX56 2021 00-NONE ,�_' t2.._, DUE TO CRASH ❑ C 2
o — 13-UNDER CARRIAGE 161 2 FIRE ID El U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016.70P 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I 6 i',_ COM VEH ❑ ® ut W
F,,, FIRST CONTACT 9 7 _, -5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 FL34640 IL 2026 REAR 4 N
IL D 0 3PCAJ5CBXMF111805 Geico ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 6245787087 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 1 03,02 l2026 03 26 ®AM in a Work Zone? ®N DIRP co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 6 n
T
0
2 ❑ 06 2 ) 1 0 PM ElConstruction
Z 3 0 lyg CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o ® 11 1 ARREST NAME Gomez. Fernando 11-601-Ax 1574000003 ! ! El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
1 2 0 ARREST NAME 03/02 12026 04 42 ®PM El Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1574-Rosales.Alexander 602 04 ,21 ,2026 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
el ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not_ To Scale I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
` ` ' ' I Ir INDICATE NORTH combination):or P3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
L I I } (example:shuttle or charter bus):or n
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
- ------------I
} I.- } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or GD
i. 'N
I I I. 4. Is used or designated to transport between 9 and 15 passengers,including (I)
}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
' .i I I I
_ t } i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). 11
,Zmt
I
CARRIER NAME Z
1 I I user _ ADDRESS 'n
J ` >
— — — — CITY/STATE/ZIP n
g
i - MOTOR CARR.ID 0 Interstate 0 Intrastate
Tw I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
:- ------- --1 -
I II
I USDOT NO. ILCC NO. m
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 VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE