HomeMy WebLinkAbout2026-00046128 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 10 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004329556
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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 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00046128 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
317 DOUGLAS AVE Elgin 04:17
® ❑ RELATED ❑Y ®N 08 01 2026 ®AM YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 icy CI Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 0FROf4T TOWED U1 0
Camarena. Mateo.A. Chevrolet Malibu 2024 00-NONE 11,• ,z DUE TOCRASH ® ❑
NAME(LAST,FIRST,M) mo yral
13-UNDER CARRIAGE 101 !:. 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn
M 2 4 SYTM❑Y ®SNE El UNK VEH. O AT CRASH 0 99-U 15- NKNOWN THER9 76•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 I, 4 COM VEH 0 Ea 1 0
~ Lake In The Hills IL 60156 B 1 0 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar U1
ZEN71312 IL 2026 REAR
TELEPHONE
IL D 0 1 G 1 ZD5ST9RF151082 n/a ®Y ❑N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Solis. Beatriz nla 2 17`6 HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
0 DRIVER N. PARKED 0 DRIVERLESS 0 PEO 0 PE0AL 0 EWES 0 row 0 Ncv 0 DV
yr ,t 12 _1 ❑ 2
o — 13-UNDER CARRIAGE 10;1 c. 2 FIRE 0 ® C
U2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 3 X
a ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracnon Value
POINT OF Sit 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S l�',_ COM VEH ❑ ® C
F,,, FIRST CONTACT 7 O7 -5 •If Yes.See Sidebar
FJ59661 IL 2026 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 1 GYS4CKJ6H R262031 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Gonzalez.Oscar 0872827-SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
1 3 07 / F 1 3 A 3 3
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/ / #OCCS >
/ / UI 2 D
/ / 0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 08/01 /2026 04 17 ®❑AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 ❑ 08 28 08/01 /2026 04 27 ❑PM ❑Construction >E
R O 0 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 0 AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Camarena, Mateo.A. 11-601-Ax 753531 08/01 /2026 04 33 ❑PM• El SLMT
igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
t 2 El ARREST NAME Camarena, Mateo.A. 3-707 753528 08/01 /2026 04 53 [M 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
1518-Versetto. Elisa 102 08 ,27/2026 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
Has a weight rating more than 10,000 pounds(example:truck or truck/trailer 1 -I
} }---_r__--; I } combination):or
0INDICATE NORTH p1
— I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
�r , 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
i I - } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
-- -- • - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
M pr t for direct compensation(example:large van used for specific purpose):or O
__ __ _ I _ 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).
it I • • -- CARRIER NAME
Z
ADDRESS 'n
w
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
Not To Scale I 0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. GVWR/GCWR m
0 <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
cn
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/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. CARGO BODY TYPE LOAD TYPE