HomeMy WebLinkAbout2026-00048339 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004337352*
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INVESTIGATING AGENCY DAMAGE TO ANY ID$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 El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00048339 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 m® ❑ RELATED PRIVATE ®Y 0 N 08 11 2026 ❑AM ❑YES El NO U1 -<
S STATE ST 1 E ROUTE 20 Elgin mo /day/yr 05:02 ®PM FLOW CONDITION m
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®25 ®/MI N E 0 Vtr S STATE ST I E ROUTE 20 COUNTY PROPERTY ❑Y MN DOORING ❑Y #OF MOTOR ❑SLOW 1 (/)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
08 /
yr 13-UNDER CARRIAGE 10. 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 02 m
M 2 SY n is-OTHER
5 ❑Y ®SNE❑UNK VEH. .AT CRAIN n SH 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH 0 Ea 1 0
~ ELGIN N I L 601 ZO 0 1 0 FIRST CONTACT 12 7 ;1 __5 *II Yes.See Sidebar U1
Z 1750217B IL 2027 E
TELEPHONE
IL D 0 1 FTRF12255NB31316 First Chicago Insurance ❑Y Il N U2 1 -
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILS1332214-00 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER •
RESPONDER D
Refused 0 Y ❑ N 2 ou
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Ru,ly 0 NOV 0 DV
�1 9$7 Nissan Versa 2014 00-NONE 'o,1 t2 c-2 DUE TO CRASH rg D U2 2 C
.. 13-UNDER CARRIAGE
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F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S .t. 4 C.OM VEH 0 ® Ut CO
FIRST CONTACT 6 O7 ,�=Q)OS •If Yes.See Sidebar C
ELGIN IL 60123 B 1 0 ET24469 IL 2027 ARg (p
•M
IL D 0 3N1CN7AP7EL863779 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 99 9 Same 979816350 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPOND 0 N U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (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 4 08,11 /2026 05 02 0 AM in a Work Zone? ®N DIRP co
1 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 0 28 25 08,11 ,2026 05 06 ®PM 0 Construction
R O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Garcia Juarez.J. R. 11-601 1543000385 08/11 /2026 05 13 Igi pM• • El SLMT
El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
T 2 El ARREST NAME Garcia Juarez.J. R. 11-305-A 1543000386 08/11 /2026 05 43 ®PM 0 Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1543-Sturgeon. Kyle 700 09 ,22/2026 01 30 ®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 truck trailer -<
` ` --I -' ° 1O it r INDICATE NORTH combination):or —I
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 X
r r 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
(L r } } } transporting employees In the course of their employment(example:employee
"0"�*�6*iiO01n° I I M! I I transporter-usually a van type vehicle or passenger car):or CO
L L.___a__ ~� 4. Is used ordesi natedtotrans transport passengers,including C} } } g po passen rs,includi the driver,
- ` r for direct compensation(example:large van used for specific purpose):or
L L--_-a-___. t i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). m
0
I
I I„ I I I -, CARRIER NAME Z
i ADDRESS O
'.o.i. D
N w
I I - CITY/STATE/ZIPg
„ Not To Scale I
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 0 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
to
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
White Gray
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