HomeMy WebLinkAbout2026-00034787 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00423435/
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00034787 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 �I
ROUTE 20 Elgin03:40
® ❑ RELATED ❑Y ®N 06 16 2026 12,— ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION III
E COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
02540,10 NOS W Shales Pk Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRO T TOWED U1 O
0 4 /
yr 0- 12 -
13-UNDERCARRIAGE 1 ! 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 4 M
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i:�S �i COM VEH 0 Ea 1 0
f. FIRST CONTACT 11 7_ —__;__5 *Ilyes.See Sidebar U1
Z Addison IL 60101 0 1 0 213607TW IL 2026 REAR
TELEPHONE
IL C 7 1 GBE4E1173F511600 None ❑Y ❑N U2 I—
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 13 c
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑Dv
!1 9$4 Nissan Altima 2011 00-NONE 111 12 -2 FIRE U2 73
C i DUE O CRASH D D 2
o 13-UNDER CARRIAGE (,
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•Top
3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN i •Oistracton Value 0
POINT OF 8 1 A r4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
FIRST CONTACT 11 7 �_5 •If Yes.See Sidebar
Z Chicago IL 60623 C 4 0 BH68966 IL 2027 REAR O C
Z
IL C 0 1 N4AL2AP7BN512868 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Chillis. Deandre 0390789SFP13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
:A
/ / UI 1 D
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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 CD 11 1 06,16 l2026 03 46 ®PM in a Work Zone? NJ DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 28 20 06,16 /2026 03 46 ®PM El Construction
>E
R 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM ❑Maintenance U2
-a, ARREST NAME Vazquez Hernandez.Josue. E. 11-601-Ax 1512680 06,16/2026 03 51 Igi pM SLMT
oN ® 11 1 •igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility
r 2 0 ARREST NAME Vazquez Hernandez.Josue. E. 3-707 1512682 06/16 /2026 04 42 ®PM El Unknown work zone type U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1512-Juarez-Huichapan.Juan 400 337-Thompson 07 ,06/2026 01 30 ®PM AM Workers present? ®N U2 45
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 -<
c ` -' -' r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
} I ® _ } (example:shuttle or charter bus):or C
3. Is designed to car 15 or fewer passengers and operated a contract carrier O
�____,-____1 I Not To3cefe_J �� - y } } } transporting employees In the course oftheiremployment(example:employee X
Unk?1 transporter-usuallya van vehicle or I I I I � type passenger car):or C
L }-----}----; l R } 1.aute720 - } 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
for direct compensation(example:large van used for specific purpose):or
__ - I t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Unttn t-- -—— �.,. placartling(example:placards will be displayed on the vehicle). D
— — — —— — - - CARRIER NAME R+L Carriers Z
1 1/ ADDRESS 375 SECOND ST
T.
w
uetns' CITY/STATE/ZIP E LG I N 1 I L/60123
MOTOR CARR.ID El Interstate 0 Intrastate
0
I I T I Not in Comm./Govt. Not in Comm./Other
❑ ❑
;-_---- --1 USDOT NO. 63391 ILCC NO. m
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. 63391 WIDELOAD'7 0 Yes ®No 2
TRAILER VIN 1 1 G R1 P9624M B227284 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 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 48 ft. 2 ft. w
Red Black
u 1 TOWED •
TOTAL VEHICLE LENGTH 60ft ft. NO.OF AXLES 4
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/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 ® VEHICLE CONFIG. 6 CARGO BODY TYPE 2 LOAD TYPE 5
Redmons/Impound Lot Garage —