HomeMy WebLinkAbout2026-00059689 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004399301
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00059689 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
DUNDEE AVE El in 11:48
® ❑ RELATED ❑Y ®N 10 01 2026 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1
Egi2 ®5 /MI N E S W Algona Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (/)
g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NOV ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FRONT TOWED U1 O
Lopez Bautista. Rosa Infiniti QX60 2014 00-NONE 11 . I_, DUE TO CRASH ❑ VI
oez
NAME(LAST,FIRST,M) p mo yr 13-UNDER CARRIAGE / 2 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2
10 (T1
F 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;iI 4 COM VEH ❑ 0 1
Z ELGIN IL 60123 0 1 0 S756378 IL FIRST CONTACT 12 T_; 6 _s Yes.See Sidebar Ut
0
REAR
TELEPHONE
IL D 0 5N1CLOMMOEC513509 State Farm Ins ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0405578-SFP-13 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
'1 9 8 1 Jeep(after 1911 ngler 2025 00-NONE 'o,� t2 c,�2 FIRE DUE D CRASH ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istraelion Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 lt, 4 COM VEH 0 ® U1 CO
H FIRST CONTACT 5 7 —_, Os •If Yes,See Sidebar
ELGIN IL 60123 0 1 0 DL555BK IL 2026 RE 0
IL 0 1 C4PJXDG7SW645461 Progressive Ins ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 10 =
Elgin Chrysler Dodge 9999768450 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 03 /
U2 4 Z
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y
N 1 ® 11 1 10/ 11 /026 11 48 ®❑PM in a Work Zone? 0 N DIRP co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME H .
AM If YES check one below: U1 7 C)
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2 0 28 2 / / ❑PM, ❑Construction
Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ®Maintenance U2
o1 ® 11 1 ARREST NAME Lopez De Bautista, Rosa 11-601 254001618 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
t 2 ❑ ARREST NAME AM
T / / pM El Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 254-Henke, Robert 200 360-Yucaitis 11 / 10/2026 ❑❑PM Workers present? ®N U2 30
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: D
N 01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer Z
` ` --I -' r INDICATE NORTH combination):or A
• BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee P3
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including UCjt
-- -- } } } g po passen rs,indudi the driver,
for direct compensation(example:large van used for specific purpose):or O
L L____a____� uma Ourt1 _ t l. I. I ._ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)thatrequires
cm sputa,4et, placardig(example:placards will be isplayed on the vehicle). XI
CARRIER NAME
Z
ADDRESS 0o T.
of
G CITY/STATE/ZIP 0
- MOTOR CARR.ID 0 Interstate 0 Intrastate g
iE
0 Not To Scale ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
0 C
• USDOT NO. ILCC NO. m
PCI
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 D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE