HomeMy WebLinkAbout2026-00028057 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00028057 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
1566 LARKIN AVE Elgin 02:45
® ❑ RELATED ❑Y ®N 05 17 2026 12,— ❑YES ®NO U1
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 3 /
yr NAME(LAST,FIRST,M) Hummer H2 2006 -NONE 11_ EN
12 `_� OUETOCRASH ❑
13-UNDER CARRIAGE 10 ` 2 FIRE 0 M <
STREET ADDRESS SEX SAFT AIR AUTOMATION IN ENGAGE
LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 M1650 M 2 3 ❑Y ®SNE DUNK VEH. 0 AT CRASH 0 015
OTHERUNKNOWN 9 16•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ij 6 4 COM VEH 0 Ea 1 00
~ ELGIN I N I L 60123 0 1 FIRST CONTACT 00 7 ;1 _5 *II Yes.See Sidebar Ut
Z FD11465 IL 2027 E
TELEPHONE
IL SGRGN23U46H111539 American Family ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Pena. Miguel 410301861046 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 CIRCLE NUMBER(S) U1
DV
yr 12 _ C
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ El U2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 9 16•TOP 3 DISTRACTED ❑ ® SPDR 0
0 0
SYSTEM IN ENGAGED 15-OTHER 0
a ❑Y El D UNK VEH. AT CRASH 99-UNKNOWN *Oistraci n Value
4 U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
6 COM VEH D ® COF,,, FIRST CONTACT 6 7A- I'_5 •If Yes,See Sidebar C
LOTR-BK IL 2026 PEAR 0 fn
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4S3GTAT63H3717479 Travelers Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Narayan. Kathleen. K. 6158433512031 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / F 2 3 0 1
m
/ / #OCCS D
71
/ / u1 2 D
/ / 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 18 1 05,18 /2026 06 53 ®AM in a Work Zone? ®N DIRP 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 0
2 D 30 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING / / ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / El PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
10
T 2 D ARRESTNAME AM
7 1 / ❑❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ❑AM Workers present? ❑Y 10
562-Hernaindez. Myra - r / ❑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 truckrtrailer -<
INDICATE NORTH combination):or —I
p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver 0
Not To Scale _ (example:shuttle or charter bus):or
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 X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____.l -
4. Isusedordesinatedtotrans rtbetween9and15 passengers,including C
} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver,
Pe ( P 9 Pe p pose):or o
L i t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
1°°6n'r`1n9Aia CARRIER NAME
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS c
❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; 0 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
Yellow Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE