HomeMy WebLinkAbout2026-00021778 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets III III 11 IIII
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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 El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 23 B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00021778 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
® ❑ RELATED ®Y 0 N 04 19 2026 ❑AM ❑YES ®NO U+ -<
WILLARD AVE Elgin12:26
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W BODE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 01 n
0 4 /
yr ++- +2 -
13-UNDERCARRIAGE + DUE TO CRASH ® ❑
1U1 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 01 M
M 2 SYTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN ENGAGED O 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 li 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 6 7_;L-Q__5 *II Yes.See Sidebar U1
Z 3917856B IL 2026 kfai
TELEPHONE
IL D 0 1 FTRX14W84NA85007 Allstate ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 856622148 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused ❑Y ® N 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 My 0 KCv 0 DV
of 5 Buick Encore 2019 00-NONE 11_"i Q�,-_1 DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10( l 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y 10 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7�� _,•.5 •If Yes.See Sidebar
H ELGIN IL 60120 0 1 0 FS79456 IL 2026 I 0
M
IL D 0 KL4CJ2SB1 KB948185 State Farm ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2186257SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 209 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(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 4 04,19 l2026 12 30 0 pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 0 28 19 1 r 0 PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME Vazquez Alcazar.Gustavo 11-501-A" Felony Comp r ! ❑PM SLMT
o N 1 ® 11 4 124 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
AM 30
t 2 El ARREST NAME Vazquez Alcazar.Gustavo 11-601-Ax 748838 r r 0 PM 0 Unknown work zone type U+
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1565-Harris.Jeffrey 202 04 ,22,2026 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
Bode 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' 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 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
\ - . - . transporting employees in the course of their employment(example:employee X
transporter-
y a van type
L L.___a__. \ usedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,indudingthedrrver,
i '; } } } for direct compensation(example:large van used for specific purpose):or
4r I L L L i. 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires A--- eat l N Po a
m
•= . Not To Scale placarding(example:placards will be displayed on the vehicle). xi
CARRIER NAME —I
ADDRESS 0
D
'a JIM
� I:. CITY/STATE/ZIP o
1 if., _ i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
i , , , O
I I T I "�"` ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
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?
❑ 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 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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