HomeMy WebLinkAbout2026-00032195 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110
111111011110111111
1
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004260739-
u, 1 U21 3 4 2 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202612026-00032195 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
VILLA ST Elgin
® ❑ RELATED ®Y 0 N 06 05 2026 ®AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 11.16 ❑PM FLOW CONDITION m
I 0 ®!MI N OE S W Willard AveNI LLA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FOR DAMAGEDAREA(S) FRONT TOWED EN
U1 0Flores Andrade.Jaun 1 2 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a 4_5 *II Yes.See Sidebar U1 COM VEH 0 j$J 1 0
F. FIRST CONTACT 12 7 ,_
Z Wauconda IL 60084 0 1 FM72061 IL 2026 "s
TELEPHONE
IL C 1 G N EC16Z64J 122698 First Chicago Ins Co ❑Y I l N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same I LS 1149644-01 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NCv 0 DV CIRCLE NUMBER(S) U1
2 0 0 1 Toyota Corolla 2015 00-NONE 11_"I QI O DUE TO CRASH ❑ 2 73
0 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C
ll
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1
POINT OF s )
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO
Im FIRST CONTACT 6 ( ,�=Q,OS •UYes See Sidebar C
0 1 FD25012 IL 2026 REAR 0 fp
M
IL D 2T1 BURHE6FC394488 Progressive ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same 965146181 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOS) (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 U2 Z
N 1 ® 11 1 06/05 ,2026 11 16 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 28 11 ) ) ❑PM, ❑Construction *
Z 3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Flores Andrade.Jaun 11-601-Ax 414-1126 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
t 2 ARREST NAME AM
7 El 7 ❑❑PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
414-Lara. Saul 401 07 ,21 /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 truck trailer -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
<----1;- --; I i I transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employee
transporter} r } transporter-usually a van type vehicle or passenger car):orco
<____A____; - ` r4 I _ Not To Scale I _ } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
_ u,* for direct compensation(example:large van used fors cific purpose):or N
-- ' r - i 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
CARRIER NAME Z
Z
ADDRESS
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
;------ --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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 White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
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
DUE