HomeMy WebLinkAbout2026-00025465 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 111111110 OI I
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00422136
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00025465 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
® ❑ RELATED ®Y 0 N 05 05 2026 ®AM ❑YES ElPRIVATE NO U1
N STATE ST Elgin mo /day/yr 11.50 ❑PM FLOW CONDITION IT1
_
15(� COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 15 u)
® �C.7/MI 1D E S W Frazier Ave WITH VEHICLES INVLD IN STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Ramirez. Monica.G. 0 5 /
yr 13-UNDER CARRIAGE 10 i ! 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 r11
F 2 4 ❑Y OS NEM❑UNK VINEH. O AET CRASH O 99-UUNKNOWN THER 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i;—L a 4 COM VEH 0 0 1 O
F. FIRST CONTACT 12 7 _,_-5 *If Yes.See Sidebar U1
Z Carpentersville IL 60110 0 1 0 FF43881 IL 2026 RFtiR
TELEPHONE
IL D 0 5FNRL38446B125486 Progressive ❑Y ®N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 976167307 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑NOV 0 NOV ❑DV
/1 9 8 8 Land Rover Range Rover 2025 00-NONE 'o,� t2 (,-2 DUE TO CRASH ® U2 2 C
o 13-UNDER CARRIAGE FIRE El
c il
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraci n Value 0
POINT OF 8 i 4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 O7 ,�_QIOS •If Yes.See Sidebar C
Z Algonquin IL 60102 0 1 0 FM 11800 IL 2027aR 0
Z
IL D 0 SALKPBE96SA294520 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 KK ENTERPRISE INC LS 3678359-SFP-13 SAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 08 /
2 O
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U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 1 51 /12 /26 11 50 ❑PM in a Work Zone? ®N DIRP D
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 28 15 / / ❑PM ❑Construction >F
Z3 ❑ j i CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
o1 ® 11 1 ARREST NAME Ramirez, Monica.G. 11-601-Ax W471000591 / / El PM SLMT
o N -
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
t 2 0 ARREST NAME AM
7 / / pM El Unknown work zone type 35
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 35
471-Evans, Lakysha 501 331-Ziegler / / ❑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
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
c ` --1 -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I - } r r (example:shuttle or charter bus):or 0
3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
l- <____A____J. - . } } } transporting employees in the course of their employment(example:employee X
0101N. 1 S 1i transporter-usually a van type vehicle or passenger car):or C
L •-----}----+ ,';�' - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
-— —— — z for direct compensation(example:large van used for specific purpose):or O
L 1 i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
' placarding(example:placards will be displayed on the vehicle). ;p
—I
\ CARRIER NAME Z
ADDRESS 0
Fra TA,e. 'i. i.' i.' i 4.
' 0CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I ❑ Not in Comm./Govt. 0 Not in Comm./Other
} i-____Y____; Not Toscaro ' _ USDOT NO. ILCC NO. m
XI
Source of above Z
0 Yes 0 No ❑ Unknown A
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue,Light White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . 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