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HomeMy WebLinkAbout2026-00013901 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 100111101011010011100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO04167779- u, 1 U21 3 4 8 U116 U2 1 U, 1 u2 1 u, 1 U2 1 1 11 U1 7 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and/or Tow Due To Crash YR 202612026-00013901 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mBOWES RD Elgin ® ❑ RELATED t3I Y 0 N 03 12 2026 ❑AM ❑YES ® PRIVATE NO U1 mo /day/yr 04:16 ®PM FLOW CONDITION m I 0 0/MI NOS S W South Randall Rd COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR ElSLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM T TOWED U1 Rosas Perez. Remi l0 1 1 / yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 m M 2 4 SYTM❑Y ®SNE DUNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, its 4 COM VEH 0 j$J 1 0 ~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *If Yes.See Sidebar Ut Z P988533 IL 2026 Isui TELEPHONE IL D 0 1GKER13768J279409 State Farm ❑v IglN U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 1082401-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 N DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 MAV 0 NCv 0 DV CIRCLE NUMBER(S) U1 /1 9 yf 3 Hyundai Santa Fe 2022 00-NONE 'o,� t2 (,-2 FIRE DUE D CRASH ® U2 2 C o 13-UNDER CARRIAGE El c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 POINT OF 8 i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�_QIOS •If Yes,See Sidebar C Streamwood IL 60107 0 1 0 DG69329 IL 2027 ii 0 to M IL D 0 5NMS6DAJ5NH430314 Liberty Mutual ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Kozodaj. Piotr A0V2431832489555 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (D0131 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 04 / F 2 4 0 1 0 m / / #OCCS > / / UI 2 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 31 /21 /026 04 16 ®PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 ❑ 28 18 / / ❑PM• ❑Construction * Z 3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Rosas Perez. Remigio 11-601 S1542-000780 / / El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 0 AM t 2 ElARREST NAME 3/ /2/ /026 04 16 ®PM ❑Unknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑y 45 1542-Chase. Ethan 702 337-Thompson 4/ / 1/ /026 09 00 p 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••--, , II A CMV is defined as any motor vehicle used to transport passengers or property and: Z I I I I I - 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< `-- -'-----' I I I I - INDICATE NORTH combination):or -I I I I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or r 144 �.v T, 3. Is designed to carry15 or fewer passengers and operated a contract carrier O r _ } } } transporting employee in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a___..I 4. Is used ordesi natedtotrans transport passengers, :(., �„ e1 } } } for direct compensation(examp large van used for specific purpose):or 0 '"Na L L----a-- : 4 - l. i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M I placarding(example:placards will be displayed on the vehicle). CARRIER NAME Z Isnw2#41 1 w w t t t n r ro sc.I-° - i. __ ADDRESS O CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn XI Source of above 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 co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Tan 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: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE