HomeMy WebLinkAbout2026-00027840 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004234493
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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 14
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00027840 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
RT20 RELATED ®Y 0 N 05 16 2026 05:22 ❑AM ❑YES ®NO U1 -<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W SHALES PKWY COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 '
❑ Cook HIT ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NW 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C)
TOWED U1 FOR DAMAGED AREA(S) FROM Q
Alcubilla Moreno. Manuel.A. 0 9 /
yr Q >2
13-UNDER CARRIAGE 19 i 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 00 r n<
M 2 SY5 ❑Y ONM❑UNK VEH. 0 AT CRASH IN 0 is-OTHER
99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i� a �i 4 COM VEH 0 0 1 0
F. FIRST CONTACT 1 7_;,-_;__5 *IIYes.See Sidebar U1
Z SOUTH ELGIN IL 60177 0 1 0 EL15839 IL 2025 REAR
TELEPHONE
IL D 0 1 G 1 PF5SC9C7360521 American Freedom Inc. ❑Y Il N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 12-2522458-00 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused 0 Y ® N 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
/1 9 8 9 Nissan Altra-EV 2023 00-NONE 1("j 12--_, DUE TO CRASH rg ❑ 2 73
.. 13-UNDER CARRIAGE 10'I c. 2 FIRE 0 ® U2 C
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
POINT OF s i 4 COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 O7 ��_QL.-5 •If Yes.See Sidebar
BARTLETT IL 60103 C 1 0 FX53834 IL 2027 i 0 N
IL D 0 JN1 DFOCD3PM701216 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 2897335-SFP-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
St.Alexius Medical Center RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL)
2 4 03 /
D
/ / 4 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 51 /61 /026 05 22 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
en
2 0 28 03 51 /61 /026 05 24 ®PM ❑Construction *
R ❑ xi CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Esteban,Janella 11-601-Ax 1561-000319 5/ /61 /026 05 28 Igi PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
t 2 El ARREST NAME 5/ /6/ /026 06 10 0 PM El Unknown work zone type U1 0 AM
45
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 45
1561-Sarovic• Mirko 401 337-Thompson 61 / /2 /26 09 00 ❑PM Workers present? ®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
Not To d I ® 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }---_r__--; _ } combination):or —I
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INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i / I I (example:shuttle or charter bus):or n
• • r 3. Is des ned to car 15 or fewer
.7....--
I r®ulwain vie g ry passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; - } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
- - for direct compensation(example:large van used for specific purpose):or O
.1. -a _ _ _ _ ; a _ _ _ _ - L L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
u
1 placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME Z
Lj _ _ _ i. i. - ADDRESS 0
_ CITY/STATE/ZIP g
1 i _ i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
1 I r 1 I ❑ Not in Comm./Gout. Not in Comm./Other
1 1 ❑ 0
• USDOT NO. ILCC NO. C
Xi
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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
Red Black
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 DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE