Loading...
HomeMy WebLinkAbout2026-00037708 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 ll 11111 li ��00I 1II1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XOD4237506 u, 1 U21 1 1 1 U1 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2026I 2026-00037708 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn 1092 BORDEN DR Elgin 05:09 ® ❑ RELATED ❑Y ®N 06 28 2026 ®AM ❑YES ®NO U1 -< _ _ PRIVATE mo !day!yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA ❑ FT!MI N E S W Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n 0 4 ! yr ,v m 13-UNDER CARRIAGE 10 1 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<rl M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 7 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it B 4 COM VEH 0 j$J 4 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_:, __5 *Ir Ves.See Sidebar U1 Z P427753 IL 2027 REAR TELEPHONE IL D 0 1 G KET16S046198632 Bristol West ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Montes.Zolia G01588463602 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV yr 13-UNDER CARRIAGE 10 ©I,, E FIRE ❑ ® U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 (ZI SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 4 X a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value POINT OF 8 ) i4 ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO F,,, FIRST CONTACT 6 O7 ,�=QI OS •IfYes See Sidebar C 3547567B IL 2027 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 0 3GCPCREAOBG121976 State Farm ❑Y J N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Tapia-Juarez. Manuel 1697529sfp13 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 Leguizamo. Maria. D. Black Mail Box struck 06,28 l2026 05 09 ®❑pM AM in a Work Zone? ®N DIRP co I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � ;, 2 ❑ 1105 BORDEN DR ELGIN IL 60120 28 18 , 1 pM ❑ , ❑Construction * Z 3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2 ❑AM ❑Maintenance U2 o ER 11 1 ARREST NAME Gasca.Alexis 11-708 S1566-000088 1 ! El PM SLMT B!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility r 2 El ARREST NAME Gasca.Alexis 11-601-Ax S1566-000087 061 28 12026 05 09 j PM El Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1566-Polovin. Matthew 202 07 , 14,2026 01 30 ElPM ®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 L A I % 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0 - } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L }-----}----+ Barden?* - • } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N men for direct compensation(example:large van used for specific purpose):or I I I /ste.? L L____a____. i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m m / �-'_- - placarding(example:placards will be displayed on the vehicle). D J */ —I ,� CARRIER NAME Z �/- N ADDRESS '0 D Not To Scale I C) . CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . xi Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El 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'; ❑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 Green White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE El NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE