HomeMy WebLinkAbout2026-00030409 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
I0110 II III IIII II IIIIII11101I
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0042 5 1 085
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 12
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and Tor Tow Due To Crash
0 AMENDED YR 2026I 2026-00030409 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 05 27 2026 12,— ❑YES ®NO U1 -<
E CHICAGO ST Elgin mo /day/yr 08 37 ®PM FLOW CONDITION III
•
®13�1!MI O E S W EAST CHICAGO St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 rA
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑Peoa_ ❑EouES ❑NOV ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 1
yr y 13-UNDER CARRIAGE 11,..I 12! 0 DUE TO CRASH ® ❑
FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED 0 Ea U2 2 m
M 2 4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 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 ii,4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut
Z Q342420 IL 2021 REAR
TELEPHONE
IL D 2T1 BU4EE8BC701368 KEMPER 0 Y ®N U2 r IL' 'I R
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
RIQUELME.CARRILLO.Q. 12RA00052832 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑
/1 9 9 9 Tesla Y 2024 00-NONE 11_"j 12'-_, DUE TO CRASH ❑ ! l 2 x
o 13-UNDER CARRIAGE 10'I c. 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraceon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si S i.1, COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 7 O7 _, _5 •IfYes.See Sidebar C
ELGIN IL 60120 0 1 0 FJ47213 IL I 0 N
M
IL A 7 7SAYGDEE3RA282675 TESLA INSURANCE COMPANY ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
M ELNYCH U K.VLASTA TLA-I L-A-9994AM MA BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 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 r 27 r2026 08 37 ®pm 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
0
2 0 28 99 + ) 0 PM• ❑Construction *
Z 3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
-a, ARREST NAME Lopez Garcia.Guadalupe 11-601 748678 / r El PM SLMT
o N ® 11 1 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
AM 45
T 2 0 ARREST NAME Lopez Garcia.Guadalupe 11-501-A-1 748679 r r 0 PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 45
1568 Baer.Amkar 300 , 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I (example:shuttle or charter bus):or
3. Is designed to} A i carry15 or fewer passengers and operated I a contract carrier O
. - ----
} } transporting employee � �In the course of their employment(example:employee X
13001E transporter-usually a van type vehicle or passenger car):or coChloBpo ' }
L fx� - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
xi*VoPel for direct compensation(example:large van used for specific purpose):or O
L L--_-a-....: P.O1,------------ t i i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
UMt2
placarding(example:placards will be displayed on the vehicle). XI
—1
Flit'I CARRIER NAME Z
ADDRESS 0
W
Not To scale Ii. c)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
0
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
) 0 Yes 0 No ❑ 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
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
Silver White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
Redmons/Impound Lot Garage . 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