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HomeMy WebLinkAbout2026-00017126 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 0011110111 0 III 0 10 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO04181764 u, 1 U2 1 1 9 U, 8 U2 U, 1 1_12 U, 1 U2 1 9 9 U1 12 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00017126 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m FORD AVE Elgin ® ❑ RELATED ❑Y ®N 03 29 2026 ®AM ❑YES ® PRIVATENO U1 mo /day/yr 08:55 ❑PM FLOW CONDITION m 05O 1C.'J!MI NOS W Ford Ave/Indian Dr COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER p PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUEs 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) .FROM Jimenez Mar uez.Alfonso 0 4 / yr 13-UNDER CARRIAGE �._Z FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 ©,Im M 2 4 ❑Y ❑SNE®UNK VEH. 9 ATCRASHD 9 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a COM VEH 0 0 1 C) 4 I— FIRST CONTACT 12 7__,--_,__S *IIVes.See Sidebar U1 0 ... ELGIN IL 60120 0 1 0 3101588B IL 2026 REAP TELEPHONE IL D 1GCGTDEN5J1274582 Bristol West Insurance Co ❑v ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m cn Reyes.Juan.C. G01366865404 9 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 XI 0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV yr �.. 12�, 73 o 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C ii; SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16 ❑ ❑ El UNK 3 9 9 X a Y N UNK VEH. AT CRASH 99-UNKNOWN *0istraelion Value POINT OF 8 it 4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 :. 6 i'.S COM Sidebar❑ ® co H FT77902 IL 2026 I> • 9 cn M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4T1 DBADK3TU555739 State Farm ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Jaime. Miguel.A. 3920736SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 O E/ MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z N 1 ® 18 1 03,29 ,2026 08 55 ®❑pM in a Work Zone? ®N DIRP co 1 I 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 0 20 28 1 , ❑PM 0 Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 -a, ARREST NAME Jimenez Marquez.Alfonso 11-601-Ax 410000808 , r El PM SLMT o N ® 11 1 ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility AM25 F 2 ❑ ARREST NAME Jimenez Marquez.Alfonso 11-402-A 410000807 , , 0 PM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25 410-DeLeon.Jessica 201 04 ,20,2026 01 30 ®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 -< ` ` --I -' I. INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X . A I I.- } 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 transporter-usually a van type vehicle or passenger car):or w L }-----}----; I } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N I for direct compensation(example:large van used for specific purpose):or O III l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires r placarding(example:placards will be displayed on the vehicle). ,Zmt —I CARRIER NAME Z ADDRESS 0 w n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------------ - USDOT NO. ILCC NO. rn XI Source of above Z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = 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? ❑ Yes II No ElUnknown A 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 Black Black 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE