HomeMy WebLinkAbout2026-00025340 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004221368
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00025340 VERY
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m
® ❑ RELATED ®Y 0 N 05 04 2026 ❑AM ❑YES ®NO U1 -<
ANNANDALE DR Elgin 07:26
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
FT!MI N E S W MISSION HILLS DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Brazier. Reonel. M. 09 /
yr 13-UNDER CARRIAGE ,( FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1UEN
O DISTRACTED 0 Ea U2 0 171
M 2 SYTM IN ENGAGEis-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16-TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL s i COM VEH 0 Ea 1 0
~ ELGIN IL 60123 C 1 0 FIRST CONTACT 2 7_; __5 *IIYes.See Sidebar U1
ZDENVERI IL 2027 REAR
TELEPHONE
IL D 0 W1 KAF4H B6N R015238 Geico ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6195079485 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EWES 0 NMv 0 N6v 0 Dv
2 0 0 5 Chevrolet Malibu 2014 00-NONE 11_"j Q�,-_, DUE TO CRASH 0 2
0Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistract on Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 . 5 •• •IfYes,See Sidebar
= ELGIN IL 60123 0 1 0 AM95942 IL 2026 I g Sn
IL D 0 1 G 11 ESSLXEU 148093 American Family ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Zamora.Jose. L. 410254697070 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
W 1 1 /
U1 1 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 4 51 /12 /26 07 26 ®PM AM in a Work Zone? ®N DIRP D
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1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 1 2 23 99 51 /12 /26 07 34
®PM• ❑Construction >F
, 4
R O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
J ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Brazier. Reonel. M. 11-1204-B 1530000715 51 /12 /26 07 37 Igi PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
AM
r 2 0 ARREST NAME 51 /12 /26 07 51 ®PM ElUnknown work zone type U1 15
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 981 61 / 12 /26 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 unitshave been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
0 ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not To1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- -----------� Scale 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 n
41i [.. i.
r X3Isdesgnedtocar 15orfewer ssen ersando rated acontract career O} } transporting employees In the courses of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} } 1. •
for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L ;__________: Ural Dr - < i. L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires M Mission?Hillsm
- N '.' - - , 1 1 placarding(example:placards will be displayed on the vehicle). ;p
ia,11 ,�. . 1
Vrs‘,..\N.Q CARRIER NAME Z
ADDRESS D
T ,
✓ 0
to CITY/STATE/ZIP n
_ MOTOR CARR.ID Interstate Intrastate
1 I r 1 I Not in Comm./Govt. o Not in Comm./Other
i. USDOT NO. ILCC NO.
Annandale?Dr m
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? 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 White
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE