HomeMy WebLinkAbout2026-00054865 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004370851
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INVESTIGATING AGENCY DAMAGE TO ANY El 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-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00054865 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ®Y 0 N 09 09 2026 ❑AM ❑YES ®NO U1
ST CHARLES ST Elgin mo /day/yr 03:59 ®PM FLOW CONDITION M
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®10((1 !MI O E S W BLUFF CITY BIVd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 6 Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 3 /
yr 13-UNDER CARRIAGE 01 ! 2 FIRE ❑
1
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 4 M
M 2 4 SYTM❑Y OS NE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER O9 16-TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Dail a �'.4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 8 7 : -_5 *II Yes.See&debar U1
Z FE59175 IL 2027 Ismi
TELEPHONE
IL D 0 KMHLM4AJ9NUO22879 ALLSTATE ❑Y ®N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 932600014 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑louv 0 Ncv ❑ CIRCLE NUMBER(S) U1
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/2 0 0 0 Mack Trucks. lOcanite 2018 00-NONE O," 12' _, DUE TO CRASH ❑ ® 14
0 13-UNDER CARRIAGE 10 E FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 0
POINT OF s i 4 C.OM VEH D ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:._ C
FIRST CONTACT 11 7 -r_5 •If Yes.See Sidebar
z AURORA IL 60506 0 1 0 054999 IL 2027 RFJ 0 Si)
IL D 7 1 M2AX13C3JM040638 FREECE OIL COMPANY ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 LESSEE/FEECE OIL CO 007-13935 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) ISEATI (DOBi (SEX) {SAFT) (AIR) (INJI ,(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 09/09 /2026 03 59 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
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2 0 2 99 / / 0 PM- ❑Construction
Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
a ARREST NAME ALFARO. EVERARDO 11-902 1571-000055 / / ID PM '
- N
1 ® ❑Utility
1 1 1 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING SLMT
o AM
t 2 El ARREST NAME 09/09 /2026 03 59 ®PM 0 Unknown work zone type U1 30
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1571-Rosas-Pereyra.Gerardo 401 / / ❑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.
Ir ----r••--, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
} } ' ' I r INDICATE NORTH
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
combination):or -<
p0
I 1BYARROW 2 Is used or designed totran ortmorethan15 C
i_ ` Not To Scale I i (example:shuttle or charter bus):or
passengers including the driver
J i a°Y N 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- }----A---•i
- ii } } } transporting employees in the course of their employment(example:employee X
ierzer,.n..zse) transporter-usually a van type vehicle or passenger car):or co
-- + - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or
- aaersrzcnenee 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
CARRIER NAME —I— — Z
ADDRESS 0
w
O
lewmutlrvetedi CITY/STATE/ZIP �MOTOR CARR.ID ❑ Interstate ❑ Intrastate
1 I r 4
; _Y_ __ I ❑ Not in CommComm./Govt. Not in Comm./Other
USDOT NO. ILCC NO. m
XI
Source of above Z
. • m
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Gray
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE