HomeMy WebLinkAbout2026-00005096 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 4 Sheets 01111101111 I00111101010 10 lID 0
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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 El$501-$1.500 El ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202612026-00005096 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
RT20 RELATED ❑Y ®N 01 27 2026 06:01 ®AM El YES ®NO U1 '<
Elgin PRIVATE mo /day/yr ❑PM FLOW CONDITION m
�5COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 99 Cl)
- FT/� N E S ® Switzer Rd WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ®Y ❑ N PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
THAMSIR.ANDRIC 0 2 /
yr 13-UNDER CARRIAGE NI
10 I !�. 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m
M I 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iII 6 1i,4 COM VEH ❑ 181 1 0
F FIRST CONTACT 11 7_;LQ,_-5 *If Yes.See Sidebar U1
Z CANTON MI 48188 0 1 0 EYN8972 MI 2026 ri
TELEPHONE
MI D 0 2T1 BURHE7HC904138 STATEFARM ❑Y igi N U2 I'13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same 6463856E04-22D 3 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 lily 0 i v 0 Dv
yr 12 _ �1
o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 a ID El 0
9 9 Y N UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iII _4 COM VEH ❑ 27 U1 COIF* j6
FIRST CONTACT 6 7—= _5 •IfYes.See Sidebar C
0 1 0 r AR 0 (/)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
Unknown El V 0 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same Unknown BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER®N u1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(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 1 01 /27 /2026 06 01 ®❑PM 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
;, 2 ❑ 37 3 28 11
! / ❑PM ❑Construction *
N 3 0 11 1 ZS!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
a THAMSIR.ANDRIC 11-601-Ax W1559-000114 / / PM
-, ® 11 1 ARREST NAME _ ❑
o U 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM 0
r 2 0 11 1 ARREST NAME 01/27 /2026 07 04 [M PM ElUnknown work zone type U1 55
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1559-DavE los.Yoana 901 393-Gutierrez / / ❑❑PM Workers present? ®N U2 55
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.
\\ A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r �....,,....., r
T20 \\ 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
Rt.c ` -'- ' \ INDICATE NORTH combination):or .Z-1
\\ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
\ - } (example:shuttle or charter bus):or
\,. T.
\ .
L . A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0
} } . transporting employees In the course of their employment(example:employee X
\ transporter-usually a van type vehicle or passenger car):or w
' I.
4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
i. i. -- - --i \\ t > 9 Po pa ge ng to
\ for direct compensation(example:large van used for specific purpose):or O
L L L L . 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
\ placarding(example:placards will be displayed on the vehicle). XI
\ CARRIER NAME Z
...a...1 \\ O
\ ADDRESS
I I I \ (
swItzer?Rdi i" L L L n
- CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
O
I i ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
�' i. USDOT NO. ILCC NO. m
Xl
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
TRAILER VIM 1 m
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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. w
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE