HomeMy WebLinkAbout2026-00012822 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 001111010 fl UI I U
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004160131
u, 9 U2 1 1 2 U1 99 U2 1 U199 1_12 U,99 U2 1 1 9 U1 1 U221 *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 El$501-$1.500 ®ON SCENE 13
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00012822 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
VILLA PL Elgin
® ❑ RELATED ❑Y ®N 03 07 2026 ®AM ❑YES ®NO U1 —<
PRIVATE
mo /day/yr 08.14 ❑PM FLOW CONDITION m
_
EO(� COUNTY PROPERTY El ® N DOORING El #OF MOTOR 0 SLOW 1 (n
C.'J!MI N E O W Villa St WITH VEHICLES INVLD IN STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN IZ V ElN PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
gi DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 NI <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y 0 N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL 6 I,.4 COM VEH 0 j$J 1 00
H 0 9 0 FIRST CONTACT 99 7_• __5 *If Yes.See Sidebar U1
ZUNKNOWN Unknown ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
UNKNOWN Unknown ❑Y ❑N U2 I—
.9 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same Unknown 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER 9 0
5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV
yr Toyota Prius 2019 00-NONE 11_i 12--_, DUETO CRASH ❑ 2 77
o — 13-UNDER CARRIAGE 10'I 2 FIRE ID El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 9 16.TOP 3 DISTRACTED 0 ® SPDR 0
0 0
SYSTEM IN ENGAGED 15-OTHER 9
a ❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN `0istrac on Value
8 4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
,.....1a11', COM VEH ❑ ® CO
F,,, FIRST CONTACT 7 L9 - ;�06 •If Yes.See Sidebar
FH82855 IL 2026 0
M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0
JTDKARFU1 K3071262 Unique Insurance ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Garcia.Jose. D. ILP3448182 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
)UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 03,07 /2026 08 17 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 99
N 3 0 CITATIONS ISSUED 0 PENDING + ) 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
z
—a ARREST NAME / / El '
o u El 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
,
10
r 2 0 ARREST NAME AM
1 r ❑❑PM ❑Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 1 O
1 Jaimes.Julian �07 , ❑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 -<
-- ' 2347vp�a? f INDICATE NORTH combination):or p0
St. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or 0
CO ` } 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 � X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__._3 - 1. •4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, (I)1 / } } for direct compensation(exam :large van used for speific purose):or
L L.._-a____. i i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
•p
rn
It:* placarding(example:placards will be displayed on the vehicle). XI
_1_`___��% - --
�;r-_,,,' CARRIER NAME Z
.�s ADDRESS O
V)n
CITY/STATE/ZIP 0
- i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
we
1 I r 1 _� ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
-- ------4. Not TO Scale I - j USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE