HomeMy WebLinkAbout2026-00040789 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI UU II� III 1101 OIl 11110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004293634
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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 3
VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202612026-00040789 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
® ❑ RELATED ®Y 0 N 07 08 2026 ❑AM ❑YES ®NO U1
W CHICAGO ST Elgin06:31
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W S STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS Eg PED ❑PEDAL 0 EDVES 0 NIIv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
FOR DAMAGEDAREA(S) Mao TOWED U1 Q
GARCIA-LARA. HARMONY, F. 1 2 /
yr 13-UNDER CARRIAGE 10 !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
F 1 SYTHER
3 ❑Y ON UNK VEH. O AT CRASH IN ENGAGEDO 99-UNKNOWN 9 16-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_i L 6 4 COM VEH ❑ 0 1
I .
ELGIN IL 60120 B 1 0 FIRST CONTACT 00 7_; _5 *II Yes.See&debar Ut
0
REAR
c Z E
TELEPHONE
NO INSURANCE El ❑N U2 15 . m
15 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 49 1 NO INSURANCE 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
o Sherman ®Y ❑ N 1 1
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NO! 0 DV
yr O 13-UNDER CARRIAGE ( E FIRE ❑ El U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:,-4 COM VEH ❑ ® U1 co
FIRST CONTACT 10 7 _, .5 •If Yes.See Sidebar
Z SOUTH ELGIN IL 60177 0 1 0 FG25668 IL 2025 RFJ O N
D
IL D 1 HGCV1 F14MA055024 GEICO ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
1 49 1 Same 6231-86-21-75 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND
El N 1 U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 71112 126 06 31 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 25 99 I ! ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
—a, ARREST NAME GARCIA-LARA, HARMONY, F. 11-1001 1568-000094 / ! ❑PM SLMT
o
u ® 12 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
t 30
AM
T ❑PM 0 work zone type U1
2 El NAME 1 / 0
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1568 Baer.Amkar 600 337-Thompson r ! ❑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
0 ADDITIONAL UNITS FORMS.
r ----r••--, , . A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r \\ ZJ r I.
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- ___ _c _ combination):or
INDICATE NORTH p1
ma �- BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} \\ �i Q�• _ ,. (example:shuttle or charter bus):or C
\\ 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
es5 pa g pe
- } } } transporting employees In the course of their employment(example:employee � X
):or
L ----------; G a� / - I. } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15r including the driver. C
for direct compensation(example:large van used for specific purose):or
L____a. A _ t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
R5� D
4.iG, CARRIER NAME Z
/ \\ ADDRESS 0\ D
\ n
CITY/STATE/ZIP\ MOTOR CARR.ID 0 Interstate El Intrastate
? Not TO Scale \\ ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
••• '-1 USDOT NO. ILCC NO. m
m
XI
Source of above 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
Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE