HomeMy WebLinkAbout2026-00018006 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M MIMI
U
�� IlU I f l 11I11I111111111 UU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004197014
u, 1 U21 3 4 1 U116 U2 1 U, 1 u2 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00018006 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
LARKIN AVE EIin 05:27
® ❑ RELATED ❑Y ®N 04 02 2026 12,— ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
0 !MI N E S Lyle Ave COUNTY PROPERTY ❑Y Igl N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® ® Y Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ® 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 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
O 6 /
yr 13-UNDER CARRIAGE 1a.1 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60124 0 1 0 FIRST CONTACT 12 7 ;1 _5 *II Yes.See Sidebar U1
Z EM94054 IL 2026 ' E
TELEPHONE
IL D 0 19XFL2H87RE017793 State Farm ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1688991SFP13 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0 row 0 i v 0 Dv
yr/1 9 8 7 Lexus ES350 2009 00-NONE ,�_-1 12--_, DUE TO CRASH ❑ C 2
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S iI S l,,_4 COM VEH 0 ® Ut CO
FIRST CONTACT 6 Y__{_0 -5 •If Yes,See Sidebar
= ELGIN IL 60123 0 1 0 ES25884 IL 2026 REAR
IL D 0 JTHBJ46G792334057 American Alliance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same I LAA108090700 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) IDOBI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 6 04 /
: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 41 !12 /26 05 27 ®PM AM in a Work Zone? ®N DIRP D
co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
o"
2 0 28 99 ! ! ❑PM• ❑Construction *
" 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a ® 11 1 ARREST NAME Ramirez. Destiny. L. 11-601 1551000358 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
0 AM
r 2 El ARREST NAME 41 112 /26 05 27 ®PM El Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1551-Dede.Joseph 602 337-Thompson 51 / 21 /026 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
' ADDITIONAL UNITS FORMS.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } .- -, , ; ; , 1, ( INDICATE NORTH combination):or -1
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' 1 , } (example:shuttle or charter bus):or
X
3. Is
L L.___A_. 1 i. ..._... . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_- , < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-.�_ ; l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 0
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
'
. Form Number
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' -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 Gray
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