HomeMy WebLinkAbout2026-00057143 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets HUI III 0 IftIl
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 23 B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00057143 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 rl
200 E CHICAGO ST El In 09:37
® ❑ RELATED ❑Y ®N 09 19 2026 DAM ❑YES IX]NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ FT/MI NESW Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --1
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Hernandez.Jose.A. 1 0 !
yr 13-UNDER CARRIAGE 10. IE
! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 rn
M 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i� a �r.4 COM VEH 0 j$J 1 n
~ SOUTH ELGIN N I L 60177 0 1 FIRST CONTACT 5 7 ; _O *lI Ves.See Sidecar U1 0
Z FM11194 IL 2026 E
TELEPHONE
IL D 0 1 G6DS57V790144509 NONE 0 Y0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same N/A 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused 0 Y ® N 2 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr .
.. 13-UNDER CARRIAGE 10( I FIRE 0 ® U2 C
II SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
0 0 16
❑
SYSTEM INENGAGED15-OTHER 9. -TOP 3 9 0 X
a Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value
POINT OF 8 -4ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 '+�.5 COM•IesVSee Sidebar ® CO
H M P22110 I L 2024 REAR O N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FM5K8ACXPGA19501 Charter Oak Fire 0 Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
99 9 Elgin 8109160P901 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) ISEATI (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 4 11 / M 2 3 0 1 0 U2 996 m
/ / #OCCS >
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 18 1 09,19 l2026 09 37 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 0 30 19 / / ❑PM 0 Construction >E
Z 3 0 DygCITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Hernandez.Jose.A. 3-707 1545000773 / / ❑PM SLMT
j$I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
o N 0 AM 10
r 2 El ARREST NAME Hernandez.Jose.A. 11-501-A-2 1545000772 / r pM Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 10
1565-Harris.Jeffrey 101 337-Thompson 10 ,05/2026 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
1. co1.mHas a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
I _ } (example:shuttle or charter bus):or
2007E7Chlcepo79t?(3rd?floor7Parldnp7Dee N T,
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
L }-----}----; ' !V - } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. (Cj)
Md. for direct compensation(example:large van used for specific purpose):or O
L____a____. V. \ _ � 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
--- placarding(example:placards will be displayed on the vehicle). Xil
JO'
_ D
CARRIER NAME —I
Z
_ ADDRESS 'n
D
_Not To Scale
CITY/STATE/ZIP
MOTOR CARR.ID ❑ Ita ❑
I I T I ❑ Notnters in Cotemm./GaA. Not inCommIntrastate ./Other
--------"1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
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
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 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: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE