HomeMy WebLinkAbout2026-00033416 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil Ill 11 IIIl
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004265211
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00033416 VENT
ADDRESS NO. HIGHWAY or STREET NAMECITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1
0 ❑ RELATED ®Y ❑N 06 11 2026 ®AM ❑YES ®NO U1 -<
N RANDALL RD Elgin04:16
_ _ g PRIVATE mo /day/yr ID PM FLOW CONDITION ITl
FT!MI N E S W H IGG I NS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
I83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
FOR DAMAGED AREA(S) FROPtf TOWED U1 O
NAME(LAST,FIRST,M) Bertand.Adrian mo
13-UNDER CARRIAGE 10 i , 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 r<11
M 2 5 ❑Y ❑SNEM®UNK VEH. 9 AT CRASD IN ENGAGE9 99-UNKNOWN 9 76•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s :il s 4 COM VEH Il ❑ 1 0
" F- EAST HAZEL CREST IL 60429 0 1 0 FIRST CONTACT 12 Y ; __s *Irves.seesidabar Ut
Z DD64286 MI 2027 ' E
TELEPHONE
IL D 0 1 FTYR1ZMOKKB30422 Hartford Fire Insurance C ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Climate Pros LLC 02CSEQU3602 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 c
m g DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 iiuv 0 Ncv ❑Dv
!1 9 9 2 Hyundai PALISADE 2023 00-NONE 11"j t2--_, DUE TO CRASH rg D 2 x
o Yr 13-UNDER CARRIAGE ta;l 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 X
❑Y ❑N IN UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI 6 l',_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._s •(ryes,See Sidebar
H ELGIN IL 60123 B 1 0 EA56548 IL 2026 IAR
M
IL D 0 KM8R7DGE1 PU632158 StateFarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Rutland Dundee Fire Camargo. Martin 1286198-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS))(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 Hometown Electric n1e light pole 61 , 1/ ,026 04 06 ®❑PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
2 ❑ 30 3 41517 US-45 Antioch IL 60002 28 99 61 ,11 ,026 04 18 PM
❑ 0 Construction >E
R O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ®AM ❑Maintenance U2
a ® 11 1 ARREST NAME Bertand.Adrian 11-306 S1522-489 61 /11 /026 04 27 ❑PM SLMT
ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility
N 50
r 2 0 ARREST NAME Bertand.Adrian 11-601-Ax S1522-488 61 1 11 /026 05 43 [o PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 50
1522-Velazquez. Noeli 901 441-Alva 71 , 41 ,026 01 30 ®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. Hasa weight rating more than 10,000 pounds(example:truck or truck/trailer -<
combination):or —I
INDICATE NORTH pI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I _ } (example:shuttle or charter bus):or
X
I A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
J I Ilir"wiii. - I. } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or desi nated to trans rt between 9 and 15 passengers, ng C}-----}----; .a.. "'" - - } } } g transport passen rs,includi [he driver,
• , for direct compensation(example:large van used for specific purpose):or
-u
t l I 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
m
I ti I v�► placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
1-1 € _ ADDRESS 0
I II w
r I I CITY/STATE/ZIP 1 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scere_J ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
I. --- --• - USDOT NO. ILCC NO. C
m
XI
' Source of above z
0 Yes J 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 ®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 Black
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 DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE