HomeMy WebLinkAbout2026-00055237 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II 10111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X019032
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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 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202612026-00055237 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 09 11 2026 ®AM ❑YES ®NO U1 -<
N STATE ST Elgin09:40
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W LAWRENCE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 C)
T TOWED U1 0NAME(LAST,FIRST.M) CERVANTES HERNANDEZ. MICAELA mo yr Chevrolet Equinox 2015 00-NONE ,,,• 12 0OUETOCRASH ® 1213-UNDER CARRIAGE 1: FIRE ❑
al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0U2 99 m
F 2 SYTM 8 ❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-U 15-UNKNOWN THER916•TOP�3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 P_COM VEH 0 E! 1 C)
I- FIRST CONTACT 1 7 : -_;_-5 *IIYes.See Sidebar U1 0
Z ELGIN IL 60120 B 1 0 FW20790 IL 2027 is
TELEPHONE
IL D 0 2GNALCEK6F6298262 UNITED EQUITABLE INS.CO. ❑Y ®N U2 1--
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same ILU033117 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y ❑ N 2rg- 0
g DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEOAL 0 EWES 0 new 0 i v 0 Dv
!1 9 6 6 Ford Taurus 2016 00-NONE 0-. Qj'-0, DUE TO CRASH 0 ❑ 98 xi
0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 9 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 1 Z 7 _, .5 •It Yes.See Sidebar
H ELGIN IL 60123 B 1 0 M210663 IL 0 I 0 C
M
IL B 0 1 FAHP2D8XGG145256 PACE INSURANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire PACE SUBURBAN BUS—F PACE INSURANCE BAC ' E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 9/ , 1/ ,026 09 40 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
453. 2 0 17 25 9/ ,1/ ,026 09 55 ❑PM 0 Construction
F
R O ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ®AM ❑Maintenance U2
-a, ARREST NAME CERVANTES HERNANDEZ. MICAELA 11-306 244001862 91 ,1/ ,026 09 58 ❑PM SLMT
o N ® 11 4 •lgiCITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
ElAM U130
t 2 0 ARREST NAME CERVANTES HERNANDEZ. MICAELA 11-501-A-2 244001863 , , ❑PM ❑Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
244-Blomberg. Michael 601 10 , 5/ ,026 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
tl,„ `. 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` ' ' ` .ro e so...sl INDICATE NORTH combination):or .Z-1
\ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
\` \ ' 4$101 r r (example:shuttle or charter bus):or C
A \ \ 3. Is designed to carry 15 or fewer passengers and operated by a contract career I O
t t t transporting employees In the course of their employment(example:employee 73
`2c• transporter-usually a van type vehicle or passenger car):or 0
L L.___a____� \ m l t I- t •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
.........„.....,..........„i„........,\.
\ for direct compensation(example:large van used for specific purpose):or
L L--_-a-___-I ack � f l. I 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
^,. placarding(example:placards will be displayed on the vehicle).
0
,N \ \11414
. 1. L. 1.._ CARRIER NAME Z
ADDRESS 'n
T.
\ CITY/STATE/ZIP 0
`` i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
r - - '- - USDOT NO. ILCC NO. m
XI
Source of above z
. 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
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. Z
Blue Silverw
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