HomeMy WebLinkAbout2026-00017328 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
M0011110MI 10111111E111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0041a5716
u, 1 U21 1 1 1 U1 2 U2 1 U, 1 u2 1 U, 1 u2 1 1 10 u1 3 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00017328 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I
319 KATHLEEN DR El In 12:12
® ❑ RELATED ❑Y ®N 03 30 2026 ❑AM ❑YES ®NO U1
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑V #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2
FOR DAMAGEDAREA(S) FROM OUETOCRASH TOWED U1 0
RAMIREZ.VILMA. N. 1 2 /
yr 13-UNDER CARRIAGE 1U 1 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 ]$I U2 2 rn
F 9 9 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 99-UUNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4 COM VEH 0 0 4 C)
F. FIRST CONTACT 12 7__,_—a_,__5 *lI Yes.See Sidebar U1 0
Z ELGIN IL 60123 B 1 0 FD97967 IL 2026 REAR
TELEPHONE
IL D 0 5J6RM4H34CL029032 UNIQUE INSURANCE CO. ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ILP2804989 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 0 N 2 eu
6U DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New ❑NCV ❑DV
Chrysler 300 2009 00-NONE 01' 0i.O, DUE TO CRASH D 2
0 13-UNDER CARRIAGE 10 i I. 2 FIRE 0 ® U2 C
c
M 2 5SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .i�..__4 COM VEH ❑ ® U1 W
FIRST CONTACT 11 7 _,r_5 C.If Yes,See Sidebar C
ELGIN IL 60120 B 1 0 EW45826 IL 2026 I 0 Si)
IL Other 0 2C3LA43D59H628195 AMERICAN ALLIANCE CAS.CO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
GUTIERREZ DERAS. BELLARMINA ILAA109233800 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused 0 Y°ND
O N U1 =
(UNIT) ISEATI (DM (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 4 01 /
:A
/ / UI 1 D
/ / 3 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 03,30 /2026 12 12 ®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 5 C)
T
o"
2 0 2 99 r / ❑PM• 0 Construction
1
N 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME1
❑AM 0 Maintenance U2
a RAMIREZ.VILMA. N. 11-902 244-1846 / ! PM '
-, ARREST NAME El
)$[CITATIONS ISSUED 0 PENDING TIME • 0 Utility SLMT
o N ® 11 1 SECTION CITATION NO. ROAD CLEARANCE 0 AM 30
t 2 El ARREST NAME MEJIA GUTIERREZ. FRELYN.S. 6-101 244-1847 r r pM 0 Unknown work zone type u1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
244-Blomberg. Michael 602 04 ,28,2026 01 30 ®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
( 0
ADDITIONAL UNITS FORMS.
r ----r•---, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r = 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
-I} }-- _r_ --; w combination):or
INDICATE NORTH 71
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i Not To Scale fl (example:shuttle or charter bus):or X
r, A 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier I O
I- --I -•i / es g pe by
�+/ } r } transporter- mpllollyyaevanthecou type rse of eorheiremployment(example employee 73
L L.___a__ ��, 51 N } } } •4. Is used or designated to transport between9a passengers,dr15r including the driver. co
C
`,.` for direct compensation(example:large van used for specific purose):or
L _ 5 Isanyvehcleusedtotransportan hazardous material(HAZMAT)thatrequires
Y -u
placarding(example:placards will be displayed on the vehicle).
0 CARRIER NAME XI
- ADDRESS 'n
, >
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
� "Y""1 USDOT NO. ILCC NO. m
XI
Source of above z
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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?El❑ Yes II No 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
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
Blue Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE