HomeMy WebLinkAbout2026-00027867 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 HH 1111 II UHI U
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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 ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00027867 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
N LIBERTY ST Elgin 07:58
® ❑ RELATED ®Y 0 N 05 16 2026 ❑AM ❑YES ®NO U1
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W SUMMIT ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR El SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
/ / FOR DAMAGEDAREA(S) FROM TOWED U1 O
Unknown.O. Unknown Unknown 00-NONE „ • 12 , DUE TOCRASH El ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE f�l !�. 2 FIRE ❑ El
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 M
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y El N DUNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
8 l 4
'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -iL 61
• COM VEH 0 0 1
I— 0 9 0 FIRST CONTACT 1 2' _5 *IIYes.See Sidebar U1 0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
N/A ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same N/A 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ElY ® N 99
!2 O Yr 0 6 Honda Civic 2026 00-NONE 13-UNDER CARRIAGE OI t2 ! 2 FIREocRASH ® U2 2 73
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 0
POINT OF s i1�I 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 8
FIRST CONTACT 11 7 -5 •If Yes.See Sidebar
Z CARPENTERSVILLE IL 60110 0 1 0 FY12003 IL 2026 0 N
D
IL Other 2HGFE2F5OTH577025 State Farn ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 MANCILLA EVERASTICO.JUAN 3397418-5FR-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 6 09 /
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/ / 4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 05/16 l2026 07 58 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
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0 1 2 0 2 20 / / ❑PM ❑Construction
Z3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 1
—a, ARREST NAME / / El PM '
oN ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,..,Utility SIMT
t 2 ❑ ARREST NAME AM
T / / pM El Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
1550-Camacho.Oscar 201 337-Thompson / / ❑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 -<
i- }--_.r-_--; A - l. INDICATE NORTH combination):or —I
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N ju°"rid BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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} (example:shuttle or charter bus):or
r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
<- --A----; 11 }} } transporting employee �In the course of their employment(example:employee
— — — — — transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L i —A JIr A-- A- t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—1
SurreraMIL Bm.nrrer. CARRIER NAME Z
ADDRESS 0
1 I
CITY/STATE/ZIP .0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; - 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
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Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Beige Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE