HomeMy WebLinkAbout2026-00028011 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 Mil it ll III flfl I11lU0111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004239766
u, 9 U2 1 9 1 u,99 uz U199 U299 U,99 U2 99 9 9 U1 99 U221 *P 0119*
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 ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00028011 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
655 CHIPPEWA DR Elgin10:46
® ❑ RELATED ❑Y ®N 05 17 2026 ®AM ID YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 99 Cl)
❑ FT!MI N E S W Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
NAME(LAST,FIRST,M) mo yr
Unknown,unknown.0. / / Unknown Unknown 00-NONE ,, -
•, OUETOCRASH ❑
Q
13-UNDER CARRIAGE 1a EN
i 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 0 m
9 9 ❑Y ❑N
SYSTEM
®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL s 4 COM VEH 0 j$J 1 O
F. Unknown UnknowrUnknown 0 9 0 FIRST CONTACT 12 7_; _5 *IfYes.SeeSidebar U1
ZUNKNOWN Unknown
TELEPHONE
UNKNOWN unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER 0
��, ❑ DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV
yr Toyota Corolla 2022 00-NONE ,._j t2'-_, DUE TO CRASH ❑ ® 99 77
13-UNDER CARRIAGE 101 2 FIRE ❑ ® U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 ❑ ® SPDR n
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 U1 0 -
POINT OF s )
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR O�_d!._ COM VEH ❑ ® CO
FIRST CONTACT 7 7 _5 •(ryes,See Sidebar
FM 11844 IL 2026 REAR
0 Si)
M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0
JTDEPMAE5NJ224336 American Freedom ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Llovera Hernandez.Orlando.J. 12-248681401 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)
0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 3 05 J 17 l2026 10 46 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 18
N 3 ❑ CITATIONS ISSUED 0 PENDING + ! ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
z
-a, ARREST NAME ! / ❑PM
o
u ® 11 2 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
25
r 2 ARREST NAME AM
7 1 r ❑❑PM El Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
486-Munoz.Jasmine 201 - / / ❑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- i----.r----; A combination)or
N INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC
U - (example:shuttle or charter bus):or X
' Not To Scale 3. Is designed tocarry 15 or fewer passengers and operated by a contract carrier I O
L. -A- --' oce es
® cnl } } } transporting employees in the course of their employment(example:employee
- I �r v' 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
L a--- I I - t i. i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
•u
- placarding(example:placards will be displayed on the vehicle). m
0
CARRIER NAME Z
ADDRESS 0
w
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
. . r . ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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
to
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
Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE