HomeMy WebLinkAbout2026-00031800 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll III 101 UI I BIOUH
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00031800 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
419 DUNDEE AVE Elgin03:33
® ❑ RELATED ❑Y ®N 06 03 2026 12,... ❑YES El NO U1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER O PARKED DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
/ ! FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Chevrolet Impala 2008 00-NONE Q 12 `_., DUE TO CRASH ❑ ENE
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I ! FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2
SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 DISTRACTED 0 0 U2
❑Y INN ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F_ FIRST CONTACT 11 7:POINT OF 6, it 6 .. 4 COM VEH 0 0 1 0
: -;__5 *If Yes.See Sidebar U1
Z DX90200 IL 2027 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
2G 1 WT55K481227497 American Freedom ❑Y ®N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Morales Lopez.Cesar 12250896600 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
'‘.3 RESPONDER XI
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5, 0 DRIVER N, PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r My 0 NOV 0 Dv CIRCLE NUMBER(S) U1
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o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 0 ® SPDR n
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *0istracton Value 9 U1 0 -
POINT OF s-.;, a
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 j' COM VEH ❑ ® CO
F,,, FIRST CONTACT 5 7 _�i.OS *IfYes,See Sidebar
EX85692 IL 2026 RFC 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2G1 FC1 EV9A9166142 Chicago Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Eli.Tapia Garc. L. ILS131859200 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (KO (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 06,03 l2026 03 33 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 15 99
N 1 3 0 CITATIONS ISSUED 0 PENDING + ! ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
z
-a, ARREST NAME / / _ ❑PM '
1 El11 1 UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
❑CITATIONS ISSUED PENDING
t 2 El ARREST NAME 06/03 12026 03 42 ®PM El Unknown work zone type U1 10
x 0 AM
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? CI Y 1 O
1500-Chew. Marie 301 , ❑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
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
- ------I-----; combination):or
4te7ouraw7wv• INDICATE NORTH P3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
3. Is designed to carry 15 or fewer passengers and operated a contract carrier
} } } transporting employees In the course of their employment
(example:--I-- employee X
transporter-usually a van type vehicle or passenger car):or w
L L.------- 4. Is used or designated to transport between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L i t i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—1
' CARRIER NAME Z
ADDRESS 0
Ili n
f,� ;ili A CITY/STATE/ZIP g
, ,
LIMA!t - MOTOR CARR.ID 0 Interstate 0 Intrastate
I .,� ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
} �I. --- -- unit 1 - USDOT NO. ILCC NO. m
m
XI
Source of above z
. 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
White Silver
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