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HomeMy WebLinkAbout2026-00053711 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110111 flfl U 1101000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X56810 u, 1 u21 2 4 1 u, 8 U2 1 u, 1 u2 1 u, 1 u2 1 1 12 u, 13 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00053711 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ' V 0 N 09 04 2026 E�IAM ❑YES ®NO U1 -< DUNDEE AVE Elgin06:04 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W SENECA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL 0 MKS 0 Nuv 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 7 ! yr HyundaiSanta Fe 2011 00-NONE DUE TO CRASH ❑©1 12 - EN 13-UNDER CARRIAGE 10 1 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ U2 0]$I m M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 6 ii,4 COM VEH ❑ Ea 1 0 H F. Elgin IL 60120 0 1 0 FIRST CONTACT 11 7_;1 __5 *IIYes.See&debar U1 Z 9 GG86958 IL 2027 REAR TELEPHONE IL D 5XYZG3AB5BG081160 First Chicago ❑Y igi N U2 19 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same ILS1216291 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ®Y ❑ N 3 2 XI N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EWES 0 uKv 0 V ❑Dv !1 9 6 4 Chevrolet Silverado 1994 Do-NONE 11 ' t2- DUE TO CRASH ❑ 2 x Ti Yr 13-UNDER CARRIAGE I FIRE ❑ ® U2 F 2 4 SYSTEM IN ENGAGED 15-OTHER 9I1,6-TOPS 0 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI 6 i_i, COM VEH ❑ ® U1 CO FIRST CONTACT 1 7�' -5 •If Yes.See Sidebar n ELGIN IL 60120 0 1 0 106681EN IL 2027 I0 Z IL D 1GCEC19K8RE117199 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 0966510SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 09,04 l2026 06 04 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 20 28 1 1 ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 o ® 11 4 ARREST NAME Macx-Velasquez. Elmer,J. 11-708 298001429W / ! El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 30 r 2 0 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 298-Lopez, Mirko 102 - / / ❑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- ' I. INDICATE NORTH combination):or531 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } } IV - r . ,. (example:shuttle or charter bus):or 3. Is desgned to carry 15 or fewer passengers and operated by a contract career O 1...°J 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 (1) } } • for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m r t m p,....Mta . . . . placarding(example:placards will be displayed on the vehicle). XI vill en —I CARRIER NAME Z ADDRESS 0 V) C) — — CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate El Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes II No ❑ Unknown A 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 Gray Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE