HomeMy WebLinkAbout2026-00037325 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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11111 10111111000100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004287413
u, 1 U21 2 1 1 U1 3 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$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 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00037325 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mDOUGLAS AVE Elgin05:46
® ❑ RELATED ®Y 0 N 06 26 2026 ❑AM ❑YES E)NO U1 -<
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT l MI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NIAv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2
FOR DAMAGEDAREA(S) FROr4r TOWED U1 0
Camacho.Jose. E. 1 0 /
yr 13-UNDER CARRIAGE i FIRE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0U2 2 m
M 2 SYTM IN ENGAGETHER
8 ❑Y ®SNE❑UNK VEH. O AT CRASH O 99-Uis-UNKNOWN 016-TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D i 6 , COM VEH ® 0 1 C)
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 9 Q _:i"- -O •Ir Yes.See Sidebar Ut 0
Z ES20947 IL 2027
TELEPHONE
IL D 0 1GNSKCKC7LR124866 Allstate ❑Y ®N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire JORDAN, Lorena 923 247 122 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m g DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NO! 0 Dv
!1 9 yf 0 Ford Explorer 2013 00-NONE 0.. Q!'-O DUE TO CRASH 0 ❑ 98 x
o 13-UNDER CARRIAGE 10( I. 2 FIRE 0 ® U2 C
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI�:,-4 COMVEH ❑ ® U1 CO
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
REAR C
Z Carpentersville IL 60110 B 1 0 M191981 IL 2027 0 Si)
D
IL B 7 1 FM5K8B83DGC30769 Self Insured ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire PACE SUBURBAN BUS Self Insured SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 61 ,61 /026 05 46 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
cii 2 0 23 26 61 /61 /026 05 46 ®PM ❑Construction
E
R 1 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Camacho.Jose. E. 11-1204-B 476000465 61 /61 /026 05 50 Igi• pM SLMT
I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
8 N AM ❑Utility
30
r 2 0 ARREST NAME Camacho.Jose, E. 11-904-C 476000466 61 /61 /026 06 53 ®PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
476-Ramos,Clarissa 102 71 / 11 /026 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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or —I
Lf— 0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r r
(example:shuttle or charter bus):or n
L L A 3. Is desgned tol carry 15 or fewer passengers and operated by a contract carrier I O
- } } } transporting employees In the course of their employment(example:employee
rter-
02
L L.___a____� 4alsuosedord�llnatedtotrans vehicle
rtbetween9andr15r) ssen rs,indudirg[hedrNer. C
1 e M t F } for direct compensation(examp:large van used for specific purpose):or 0
< <____a____.I Q' 'r'r"ii9i1xi t i } i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
i D
—01 r CARRIER NAME
urns o
' __ ADDRESS
T.
Not To Scale I CITY/STATE/ZIP I n
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
i. --- '-4. - USDOT NO. ILCC NO. m
Source of above z
. ❑ 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 ®No 2
TRAILER VIN 1 m
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE