HomeMy WebLinkAbout2026-00027546 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO04235275
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-S1,500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00027546 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 15 2026 ®AM D YES ®NO U1 -<
BLUFF CITY BLVD Elgin08:54
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
U2 —I
lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EOUES 0 Nuv 0!Cu 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGEDAREA(S) FROM TOWED VI
U1 0Blanco Me Ia. Hector.A. 0 3 /
yr
13-UNDER CARRIAGE 161 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 3 <<T1
M 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 15-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i1 6 �i, COM VEH 0 0 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 1 7_; __5 *Ilves.See Sidebar U1
Z FG78429 IL 2026 REAR
TELEPHONE
IL D 3N 1 AB7AP2KY432572 Safeway ❑Y ®N U2 MI—
Si
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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1 99 9 Same 3995833-I L-PP-006 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El El 2 0
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0!My 0 Ncv 0 Dv
/1 9 9 3 Chevrolet Impala 2014 00-NONE 11 12 t2 "_, DUE TO CRASH 0 2
0 13-UNDER CARRIAGE o 1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 0916•TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *0istraction value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 'i 6 i!,_ COM VEH ❑ ® u1 W
FIRST CONTACT 8 7 _, _5 •IfYes.See Sidebar C
E LG I N I L 60120 0 1 0 AU 23260 I L 2026 I Si)0
IL D 2G 1125S3XE9126410 Allstate ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 811321942 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 4 51 (51 )026 08 54 ❑pM in a Work Zone? ®N DIRP co
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 ,,
0 2 0 20 15 ( ( 0 PM ❑Construction *
Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 4 ARREST NAME Blanco Mejia. Hector.A. 11-708 435000743 / ! ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
AM U, 35
t 2 El ARREST NAME 51 (51 1026 09 00 [M PM El Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
435-Mahan. David 401 360-Yucaitis 61 , 12 (26 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.
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 truck trailer -<
• i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 i. <--_- -___� J transporting employened to es inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_, , < <--_-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 ...._-.�____� 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). m,Zt
--I
CARRIER NAME Z
ADDRESS 0
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
. 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'; 0 Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Silver
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