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HomeMy WebLinkAbout2026-00061552 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111 111111111111110111111111111 0110 I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X489•66 u, 1 u21 1 1 1 u, U2 1 u, 1 u2 1 u, 1 U2 1 5 10 u1 3 U2 3 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00061552 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 rn VILLA ST Elgin® ❑ RELATED ®Y ❑N 10 09 2026 08:07 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W S GIFFORD FFORD ST COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 2 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑Peon. ❑EouES ❑KIN ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 0 5 / yr 13-UNDER CARRIAGE ©i O'- FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 0 0 U2 3 <<T1 M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i1 6 �i,4 COM VEH 0 j$J 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_;{ __5 *Ilyes.See Sidebar U1 Z3450544B IL 2027 REAR TELEPHONE IL D 1 FTSE3ELODDA60907 State Farm ❑v ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Toko Electric LLC 3863963sfp13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 eu m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 /1 9 9 2 Ford F150 2004 00-NONE ,�_"i 12'-_, DUE TO CRASH 0 2 0 Yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN CO 0istraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII 6 , 4 COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 5 Y rj= 1 •(ryes,See Sidebar C ELGIN IL 60123 0 1 0 GB47315 IL 2027 i Si)0 M IL D 1 FTPX14584NA22679 American Freedom ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same 12252586000 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER ui = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 05 / M 2 3 0 1 0 m / / #OCCS D Xl / / U1 1 D / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 10/09 /2026 08 05 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) O 2 28 03 / / ❑PM ❑Construction * Z 3 0 I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Vieyra Gaona. Fernando 11-601 1545-785 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility AM r 2 El ARREST NAME 1 / ❑❑pM El Unknown work zone type U1 3O 2 2 3 ID Am ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1545-VanEycke. Brier 101 337-Thompson 10 ,27/2026 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 e 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 -< ---- -----; Not To Scale I I combination):or -I INDICATE NORTH p1 r-... 1 L. i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver -:. i _ } (example:shuttle or charter bus):or X 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 lP C L L.___a__... - - 4. Is used or designated to transport between 9 and 15 passengers,including the driver, / unrtz 4r,}, II . . . for direct compensation(example:large van used for specific purpose):or L L____a____. I I. i i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires u placarding(example:placards will be displayed on the vehicle). m A ' /..--1 _ CARRIER NAME ADDRESS Z 'Z T. r r T 1 I r i. i. i. i. 4. CITY/STATE/ZIP n IoRrvnner - MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other i- --- --1 USDOT NO. ILCC NO. m XI Source of above z . 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE