HomeMy WebLinkAbout2026-00029833 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 11111M
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004246738
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1,500 ❑ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00029833 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
1227 DUNDEE AVE Elgin07:30
® ❑ RELATED ❑Y ®N 05 25 2026 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED p PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 0
! ! FOR DAMAGEDAREA(S) FRO t TOWED U1 O
NAME(LAST,FIRST,M) Unknown. Unknown.0. mo yr Unknown Unknown 00-NONE
OUETOCRASH ❑11 12 - EN
13-UNDER CARRIAGE 10 i 2 FIRE 0 IE
•STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ga U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ID N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL s l'.4 COM VEH 0 Ea 1 0
I— 0 9 FIRST CONTACT 99 7_; _-5 *If Yes.See Sidebar U1
ZUNKNOWN ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
UNKNOWN Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
5HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 X
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr 12 _1 DUE TO CRASH ❑ 2 ,'�
13-UNDER CARRIAGE 10;I c. 2 FIRE 0 El U2 C
..
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 X
a ❑Y ®N D UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
POINT OF s-.;, -4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 1!:,,,,COM VEH ❑ ® CO
F,,, FIRST CONTACT 5 7-. _, S •If Yes.See Sidebar
2215550B IL 2027 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3G N FK16398G 190441 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Juarez.Juan. E. 811 590 654 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEATI (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)1ITELEPHONEI (EMS) (HOSPITAL)
0 O
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 05 125 /2026 01 00 0 pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 99
N 3 0 ❑CITATIONS ISSUED ID PENDING •
+ ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a, ARREST NAME / / El PM '
o N 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
SLMT
❑ 99
f 2 0 ARREST NAME AM
7 1 r ❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 99
1555-Maldonado. Daniels 201 r ! ❑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
_ ® Not To Scale , 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer
c •__ —1-- r INDICATE NORTH combination):or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
- } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
i.
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
v` 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L l. L I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
h i •1227YOrmds9At err
placarding(example:placards will be displayed on the vehicle). �
-I
CARRIER NAME Z
ADDRESS 0
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"---- --1 - USDOT NO. ILCC NO. rn
Source of above Z
. ❑ Yes 0 No 0 Unknown E
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No 0 Unknown A
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' T
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gold
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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE