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HomeMy WebLinkAbout2026-00030635 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 ll III OH UI lI111IODU DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004255315 U1 1 U21 3 4 1 u, 8 U299 u, 1 U2 1 u,99 U2 99 5 10 u, 4 U2 1 *P0119* 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 ❑5501-51,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00030635 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 N MCLEAN BLVD Elgin® ❑ RELATED ' ' 0 N 05 28 2026 ❑AM ❑YES ®NO U1 -< 10:19 PRIVATE mo /day/yr ®PM FLOW CONDITION m _ FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 cn ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) FRONT TOWED NAME(LAST,FIRST,M) Rodriguez Perez. Karlo.A. mo yr Ford Escaa U1 O 2009 p 00-NONE t i, 12 Q DUE TO CRASH ❑ E 13-UNDER CARRIAGE FIRE 0IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED ® 0 U2 3 <<T1 M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H 0 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a �i 4 COM VEH 0 Ea 1 0 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 1 7 ;- -_5 *IrYes.See Sidebar U1 Z EW60180 IL 2026 7 TELEPHONE IL D 0 1 FMCU03G39KB39627 Progressive ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Rodriguez Gomez.Juan.A. 976689199 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 7] x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 RGV 0 DV Yr 13-UNDER CARRIAGE 9 I ©). 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 4 i1�i-4 COM VEH ❑ ® U1 CON CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 FIRST CONTACT 11 8 7 _5 •(ryes.See SidebarC z ST CHARLES IL 60175-7787 0 1 0 FY54740 IL 2026 REAR 4 ((I) IL D 0 W1 N4M4HB9TW481816 American Family ❑Y J N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same 410525209874 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z N 1 ® 11 1 05 128 /2026 10 19 ®PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � o" 2 ❑ 20 28 1 1 0 PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 -a, ARREST NAME Rodriguez Perez. Karlo.A. 11-709-D 1525001020 1 ! ❑PM SLMT 1 ® 11 4 CITATIONS ISSUED 0 PENDING Utility o uSECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑ t 2 El ARREST NAME Rodriguez Perez. Karlo.A. 11-601-Ax 1525001022 05128 ,2026 11 56 ®PM El Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1525-NavE.Oscar 502 06 1 23,2026 09 00 0 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 0 ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and:I Z II I Not To Scale ' 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer - i- }---.r----; I I I } combination)or INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC II I - (example:shuttle or charter bus):or 3. Is designed to carry15 or fewer passengers and operated a contract carrier O }----------i ` I.-} transporting employee �In the course of their employment(example:employee Untt 2._..) I I I } transporter-usually a van type vehicle or passenger car):or w L L.___a_ 4. Is used or designated to transport between 9 and 15 passengers,including the driver. - I. } } for direct compensation(examp large van used for specific purpose):or O L ..i.. . - - L i. i i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires .D placarding(example:placards will be displayed on the vehicle). m 0 CARRIER NAME I I ADDRESS O D III w 0 CITY/STATE/ZIP g - MOTOR CARR.ID 0 Interstate 0 Intrastate 1 1 r 1 I I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 ------- --4. I I I - : USDOT NO. ILCC NO. m m Source of above 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 VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE