HomeMy WebLinkAbout2026-00033779 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI U� I� lii 11UUI HHIUUIUUIDUU
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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-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00033779 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 17 71
® ❑ RELATED ®Y ❑N 06 12 2026 ❑AM ❑YES ®NO U1
HILL AVE Elgin06:45
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT!MI N E S W PARK ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El 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 NIAV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 3 !
yr
Nicanor.Jonathan Unknown Unknown 00-NONE ,, -
•, DUE TOCRASH ® ❑
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13-UNDER CARRIAGE tU i 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 O 171
M 5 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 76•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL B 4_5 *IIYes.SeeSidabar U1 COM VEH 0 Ea 1
0
c Z FIRST CONTACT 12 7
ELGIN IL 60120 0 1 9 _;REAR
TELEPHONE
IL D MZJY2024T4AUL0017 None ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 52 1 Same None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 0
E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0 i v ❑DV
!2 0 0 5 Ford F150 2013 00-NONE 0. 12..-_, DUE TO CRASH 0 2 x
o 13-UNDER CARRIAGE 10� 2 FIRE 0 ® U2 C
ll
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 .iA_d..__4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7 _5 C.
IfYes.See Sidebar C
ELGIN IL 60123 0 1 0 3908642B IL 2027aR Si)0
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IL D 1 FTFW1 ET4DFC93132 Amigo Insurance Co. ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Guadalupe. Leon ILU017623 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 3 04 /
UI 1 D
/ / 2 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 06,12 ,2026 06 45 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 23 28 06,12 ,2026 O6 45 PM
® . ❑Construction %
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
ARREST NAME 06,12,2026 06 48 ®PM
1 ® 1 1 4 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
o 2. N SECTION CITATION NO. ROAD CLEARANCE TIME 0
D AM
r 2 ElARREST NAME 061 12 12026 07 25 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1545 VanEycke. Brier 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.
. 0
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
iL co 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
-<
` ` ' ' r INDICATE NORTH combination):or p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
Not To Scale X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
1 } } 1. transporting employees In the course of their employment(example:employee X
l transporter-usually a van type vehicle or passenger car):or w
Unit 2 } } 1. 0
•4. Is used or designated to transport between 9 and 15 passengers,including the driver. to
for direct compensation(example:large van used for specific purpose):or O
L I t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
A placarding(example:placards will be displayed on the vehicle).
Untt71 - D
CARRIER NAME —1
Z
ADDRESS 0
V)
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __.; USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE