HomeMy WebLinkAbout2026-00022790 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 mil 11 111111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00022790 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
VILLA ST Elgin
® ❑ RELATED ❑Y ®N 04 23 2026 Ilk. ❑YES El NO U1 —<
PRIVATE mo /day/yr 02:56 ®PM FLOW CONDITION ITI
®15((1 !MI N E S ® East National St/Villa St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 fA
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NOV ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
0 6 / yr
Chevrolet Trail Blazer 2003 00-NONE DUE TO CRASH ❑ EN
11-_ +2 -
13-UNDER CARRIAGE 10l • 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 3 I<T1
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
M 2 4 0 0 2
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iII 6 ii,4 COM VEH 0 Ea 1 0
F. ELGIN N I L 60120 0 1 0 FIRST CONTACT 6 7_;LQ--5 *If Yes.See Sidebar U1
ZFF75752 IL 2026
TELEPHONE
IL D 0 1 G N DT13S132161520 Statefarm Insurance ❑Y ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0104858SFP13 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 ❑DRIVERLESS 0 PEO ❑PEDAL 0 EWES ❑ uv 0 Ncv ❑Dv
Yr 1 9 9 9 O Acura TL 2007 oo-NONE ,�_' 12 "_, El
TO CRASH ❑ 21 1
O 13-UNDER CARRIAGE ( 2 FIRE ❑ U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJi N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractlonValue 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.I. 6 11:,-4 COM VEH ❑ ® U1 co
FIRST CONTACT 10 7� , 5 •If Yes.See SidebarC
H ELGINZ IL 60120 0 1 0 EY91326 IL 2025 RFJ 0
M
IL D 0 19U UA76567A037425 Statefarm Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3907289SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 1 04,23 (2026 02 56 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 ❑ 30 99 ( ( 0 PM ❑Construction *
R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Funes Cifuentes.Juan. B. 11-1402-A W1500000400 ( r El PM SLMT
S? N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
0 AM
r 2 El ARREST NAME 04/23 (2026 02 56 ®PM El Unknown work zone type U1 35
o T
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 35
1500 Chen. Marie 301 , ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -.-- --; ; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. 1 ..._.... J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..i.____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. xi
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
Black White
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE