HomeMy WebLinkAbout2026-00005461 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00005461 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
TODD FARM DR El In05:48
® ❑ RELATED ®Y 0 N 01 28 2026 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT N E S W ROBINWOOD DR COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 1 0)❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE .I FIRE 0
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STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 00 m
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SYSTEM IN ENGAGED 15-OTHER 9 Is-b 3
M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN -
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1 B �I COM VEH 0 0 1 n
I- 0 9 0 FIRST CONTACT 3 7_: R -5 *II Yes.See Sidebar U1 0
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TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
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99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
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!1 9 yr 3 Chevrolet Malibu 2014 00-NONE ,i ' t2 ®DUE TO CRASH 0 2 x
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
POINT OF s i1 4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR .A 5 Lf._
FIRST CONTACT 1 7� _,-_5 •IT Yes,See Sidebar
— Elgin IL 60123 0 1 0 AM95857 IL 2026 RFJ 0 C
IL D 0 1 G 11 C5SL1 EF145030 Geico ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Gutierrez. Miguel 6225-65-25-58 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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(UNIT) (SEAT) (DOB) (SEX) {SAPT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)l(TELEPHONEI (EMS) (HOSPITAL)
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EI MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 01 r 23 12026 05 48 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n
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2 0 2 28 ) I ❑PM• ❑Construction X
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- N ®a ARREST NAME / / ID PM '
1 11 4 ❑Utility
0 CITATIONS ISSUED ❑PENDING SLMT
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SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM
T 2 0 ARREST NAME 01 128 12026 05 48 ®PM ElUnknown work zone type U1 25
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 25
1561 Sarovic• Mirko 501 320-Cox / ❑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
i- ___ __ • - Not To Scale I ® _ comWnation):orra gmore thanpound (example:truck ortruckrtraller -I• tin 10,000 s
` --I-- ' I r INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
PlepsaAr. t+oenn►m,.urer+rn I (example:shuttle or charter bus):or 0
I- ------I----; I transporting employeened to s Inthe course 5 or fewer�o rhea emrs apbyment nd example contract
emp>oyeener
} } }
transporter-usually a van type vehicle or passenger car):or
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L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } } g Po passen rs,includi the driver,
® for direct compensation(example:large van used for specific purpose):or
��>` } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
'� placartling(example:placards will be displayed on the vehicle). ;p
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!Uliwee8>tee: CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
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Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE