HomeMy WebLinkAbout2026-00026987 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets III III 11 IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
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 for Tow Due To Crash
0 AMENDED YR 202612026-00026987 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
E CHICAGO ST Elgin05:13
® ❑ RELATED ❑Y ®N 05 12 2026 12— ❑YES ®NO U1 -<
g PRIVATE mo /day!yr ®PM FLOW CONDITION m
0 !MI N E S W Poplar Creek Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15
® O p Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) •FROM TOWED U1 0Hannah. Lamarvion 1 1 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY 15-OTHER
4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r a ii, COM VEH 0 Ea 3 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4
ELGIN I L 60120 0 1 FIRST CONTACT 11 7-;1 -__5 *lives.See Sidebar U1 0
Z EC44929 IL 2026
TELEPHONE
IL D 0 1 FADP3E25EL225583 State Farm ❑Y ®N U2 nni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
GARDUNO MERCADO. LUIS.J. 1277937-SFP-13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 0 N 2 eu
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0
aay '1 9 Yr 7 Jeep(after 1911ng!er 2018 00-NONE +i_"' 12'-_, DUETO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y 181 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si 6 ...4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 6 7 -�--'6•(ryes.See Sidebar C
ELGIN IL 60123 0 1 EX83431 IL 2027 REAR 0 N
IL D 0 1 C4HJWDG5JL877786 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3517359-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 05,12 i2026 05 13 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
si T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
•0
2 ❑ 28 10 1 1 ❑PM ❑Construction *
Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Hannah. Lamarvion 11-601 S1529-000745 / r El PM SLMT
S' N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
35
T 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D 1529-Audi red.Jonathan 302 393-Gutierrez 06 ,02/2026 09 00 0 PM Workerspresenl7 ®N U2 35
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 -<
` ` --I -' r INDICATE NORTH combination):or -I
7 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Poplar?Creek?Dr. X
- r r r (example:shuttle or charter bus):or
/ 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I- <_---A----i }} } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or co
-----------; 44 } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
/ for direct compensation(example:large van used for specific purpose):or
L L____a____.I ` _ t i. ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
III
placarding(example:placards will be displayed on the vehicle). XI
Z
.---- „ems CARRIER NAME Z
0
_ _ _ __ ADDRESS D
Not To Scale I V7
E?Chicago?St. CITY/STATE/ZIP 0
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MOTOR CARR.ID 0 Interstate 0 Intrastate
0
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
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
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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
Silver Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE