HomeMy WebLinkAbout2026-00032304 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 0110 11111 IM I 1101111/
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2026I 2026-00032304 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
S EDISON AVE Elgin08:43
® ❑ RELATED ®Y 0 N 06 05 2026 ❑AM ❑YES N NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W VAN ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 I Cv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 1 0f4T�TOWED U1 0NAME(LAST,FIRST,M) Chavez. Luis mo Lexus IS-F 2016 00-NONE 11_' Q 17T OUE iO CRASH ® ❑
13-UNDER CARRIAGE i , 2 FIRE ❑ N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 1 r r1<
16
THER
M 2 4 SYTM❑Y INN NEDUNK VEH. 0 ATCRASHD 99-UUNKNOWN 9 ,6•TOP 3 `Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,.4 COM VEH 0 E! 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar U1
Z AVA17-WS I L 2027 REAR
TELEPHONE
IL D 0 JTHCM1 D27G5007414 Statefarm ❑Y IlN U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Elgin Fire 1 99 9 Sanchez. Manuel. E. 1097112SFP13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 X
g DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 N,Iv 0 NCV 0 DV
!1 9 9 2 Chevrolet Trax 2018 00-NONE 1("j 12..-_, DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE 1 FIRE ❑ N U2
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN Oistraebon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 I( 4 COM VEH ❑ N U1 COFIRST CONTACT 3 7 . -5 *If Yes.See Sidebar
m ELGIN IL 60123 B 1 0 S287503 IL 2026 I g Sn
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IL D 3G NCJ LSBXJ L207274 Progressive ❑Y N N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 99 9 Same 977618319 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER Y ® 4 U1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJ) i(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 N 11 1 06,05 /2026 08 43 ®AM in a Work Zone? NCI N DIRP co
1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1
;, 2 ® 1 3 23 15 06,05 ,2026 09 04
®PM
• ❑Construction *
R O ❑ CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM D Maintenance U2
o 1 ® 11 1 ARREST NAME Chavez. Luis 11-601 1553000388 06/05/2026 09 09 Igi PM• • 0Utility SLMT
I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
Ti 2 N 1 3 ARREST NAME Chavez. Luis 6-107-G 1553000389 06/05 /2026 11 13 N PM ❑Unknown work zone type U1 20
2 2 3 ElOFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM workers present? ❑Y 20
1553-Jentsch.Clarissa 601 337-Thompson 06 ,23,2026 09 00 ❑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 truckrtrailer -<
i- }--_-r----; } combination):or
INDICATE NORTH �
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - } r r r (example:shuttle or charter bus):or 0
< <---- -•-•; i 1 I 1 transporting mployeened to sl5 or fewer In the course passengers thir emplod yment example:employeener x
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} } }
transporter-usually a van type vehicle or passenger car):or co
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g Po passen rs,includi the driver,
vows. for direct compensation(example:large van used for specific purpose):or O
` _Ir"Ft i`i H L } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
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placarding(example:placards will be displayed on the vehicle). ;p
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CARRIER NAME . 1
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ADDRESS 'n
V)
MOTOR
I .
411111 [
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE