HomeMy WebLinkAbout2026-00027458 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202612026-00027458 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 14 2026 ❑AM ❑YES ®NO U1 -<
S MCLEAN BLVD Elgin07:06
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
1 2 /
yr 13-UNDER CARRIAGE 1U • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 4 rn
F 2 4 ❑Y ®Nn is-OTHER
SYSTEM
❑UNK VEH. AT CRASHD 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a 4 COM VEH 0 Ea 1 O
F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1
Z SOUTH ELGIN IL 60177 B 1 0 ZU43429 IL 2027 REAR
TELEPHONE
IL D 0 3N 1 AB7AP6GY210477 State Farm ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Ruiz. Martha 2890496SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 NW 0 NCV 0 Dv
2 0 0 7 Audi Q5 2018 00-NONE a i Q!'-O DUE TO CRASH rg ❑ 2 x
0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
POINT OF 8 i1�i 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B -s •• •IfYes,See Sidebar
ELGIN IL 60123 0 1 0 GB29574 IL 2027 I 0
So
IL D 0 WA1 BNAFY7J2047829 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 873680890 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 05(14 (2026 07 06 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 2 99 05,14 (2026 07 08 ®PM El Construction
*
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
J ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Ruiz. Melanie. B. 11-901 S1551000366 05(14 r2026 07 11 ®PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 ElARREST NAME 05(14 (2026 07 43 ®PM ElUnknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1551-Dede.Joseph 701 06 (09(2026 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.
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____; I I I - I. INDICATE NORTH combination):or -I
II BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
C) (example:shuttle or charter bus):or
L L. r 1 1 �r 7bScale_ 3. Is designed tocarry 15 or fewer passengers and operated by a contract carrier I O
--A----' r J } } } transporting employees In the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or CO
L -----------+ 4 - } } } 4. Is used or designated to transport between 9 and 15 passen rs,including the driver. C
1 ) - Y for direct compensation(example:large van used for specific purpose):or to
L �____a..... � l. I • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
2#
\ CARRIER NAME Z
1 1 I ' 6)
ADDRESS
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. 0
I I I CITY/STATE/ZIP g
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I 1 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
------ ----4. - USDOT NO. ILCC NO. m
m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD? ❑Yes 0 No 2
TRAILER VIN 1 m
to
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
Gray 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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Mies/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE