HomeMy WebLinkAbout2026-00017415 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III III 11 IIII
UH UU I IlU IflII1 111I11I1UU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X604199281
u, 1 U21 3 4 1 U1 8 U21 O U, 1 u2 1 U, 1 U2 1 1 12 u, 2 U2 2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2026I 2026-00017415 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 "I
LARKIN AVE El In 06:22
® ❑ RELATED ®Y 0 N 03 30 2026 DAM ❑YES El NO U1 "'<
g PRIVATE mo !day!yr ®PM FLOW CONDITION ITl
FT N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
IE3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 4 0
Y N
1 2 /
yr 13-UNDER CARRIAGE I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) O 2 DISTRACTED 0 ]$I U2 4 M
M 17 3 SYTM❑Y ®SNE❑UNK VEH. O ATCRASHD 0 15-99-UUNKNOWN THER O9 t6-TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� B 4 COM VEH 0 Ea 1 n
ELGIN N I L 60120 A 2 8 FIRST CONTACT 99 O7 _; __5 *If Yes.See Sidebar U1 0
ZNIA NA 2026 ' E
TELEPHONE
IL D 0 JYARJ12E96A005926 NONE ❑Y ❑N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same NONE 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 ou
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 Ncv ❑Dv
!1 9 9 0 Ford F350 2002 00-NONE 11_"j t2--_, DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10 c, 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN O *0istracl on Value 9
POINT OF 8 )��f"4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR .{ 5
FIRST CONTACT 4 7�_ _OS •trYes.See Sidebar
Elgin IL 60120 0 1 0 177311F IL 2026 REAR 9 n
IL D 0 1 FDWF36FX2EC51308 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Juanchi-Serrano. Maria. L. 507657830 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI j(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 8 02 /
, D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 03,30 /2026 06 22 ®AM 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
0 2 0 04 28 , , ❑PM ❑Construction >F
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a ® 11 1 ARREST NAME Alvarez.Gabriel. E. 11-601 S1519-000515 , ! El PM SLMT
igi CITATIONS ISSUED ❑PENDING NSECTION CITATION NO. ROAD CLEARANCE TIME AM•
❑Utility
o T 2 El ARREST NAME Alvarez.Gabriel. E. 3-707 S1519-000513 03/30 ,2026 07 45 ®PM El Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1519-Bae2 a.Guadalupe 602 05 ,04,2026 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
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 -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
I I [
I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- <.__-A-.--I t - y } } } transportingemployees In the course of their employment
pbyment(example:employee 73
_ Muensow; transporter-usually a van type vehicle or passenger car):or CO
I I< .. 4. Is used or designated to transport between 9 and 15 passengers,including y
}--- ----; c"""t7~"' - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L i.____a.....l - t i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
tM
m
placarding(example:placards will be displayed on the vehicle). ;p
sx I I CARRIER NAME Z
I I __ ADDRESS
I I 7MOL►an7DWa VV)
CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
Xl
_ Source of above Z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 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 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE