HomeMy WebLinkAbout2026-00027501 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets II III H IIII UHI
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004238910
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00027501 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ❑Y ®N 05 15 2026 ®AM ❑YES ®NO U1 -<
PROSPECT BLVD Elgin00:22
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W SENECA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ 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
Q83 DRIVER (] PARKED O DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FROr T TOWED U1 0
Unknown.0. Chevrolet Traverse 2012 00-NONE 11 . 12 DUE TOCRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑ al <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2
9 $ SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 0
0
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❑Y ®N ❑UNK VEH. ATCRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 ii,4 COM VEH 0 j$J 1 00
~ 0 1 0 FIRST CONTACT 1 7_; __5 *lIVes.See Sidebar Ut
Z FG92482 IL 2026 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED I I
3G NAL3E5XCS638147 Kemper ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
99 9 VILLAGOMEZ CONTRERAS. Elena 12RA000095924 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
'‘.3 RESPONDER
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0 DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 l My 0 NOV 0 DV
yr 10 j t2 (, 2 FIRE ID ElU2 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9:1,6•TOP 3 ❑ ® SPDR 0
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN ••0istracton Value Ut 9
POINT OF 8-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 j�',_ COM VEH D ® CO
F,,, FIRST CONTACT 7 Q __,ti_5 •If Yes,See Sidebar
DR55298 IL 2026 REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3C4PDCABOCT204373 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
99 9 GUTIERREZ MACEDO. Noemi 972273623 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 05,15 l2026 00 22 ®❑AM
in a Work Zone? ®N DIRP co
1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 18
N 3 ❑ CITATIONS ISSUED 0 PENDING + ! ❑PM- ❑Construction >E
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME / / ID PM '
1 El 11 1 ❑CITATIONS ISSUED PENDING • UtilitySLMT
N SECTION CITATION NO. ROAD CLEARANCE TIME
o ❑
AM U1 30
t 2 ❑ ARREST NAME 05/15 /2026 01 00 [M PM ❑Unknown work zone type
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 30
1560-Jones. Bennett 102 , / ❑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
r a.o.nVA. ADDITIONAL UNITS FORMS.
r r----r-•--, I - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not To Scale I more than pounds(example:truck or truck trailer -<
W 1. Has i weight rating10,000
i- ;.__-_r_-_-; I I. combination):or
INDICATE NORTH C-1
'� BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver and:
- } (example:shuttle or charter bus):or 0
X
L A - - - - - - 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
L L.___a____1 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
t } } for direct compensation(example:large van used for speific purose):or 0
i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
-I-- I placarding(example:placards will be displayed on the vehicle). XI
IUna we CARRIER NAME Z
ADDRESS 0
T.
rn
n
.1'.r, CITY/STATE/ZIP g
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate
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' ❑ Not in Comm./Govt. Not in Comm./Other
❑ 0
i. --- '-1 - USDOT NO. ILCC NO. m
I XI
Source of above z
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Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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? 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
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
Black White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE