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HomeMy WebLinkAbout2026-00029012 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 II III flfl I 0111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004235646 u, 1 U21 3 4 1 u, 2 U2 1 u, 1 u2 1 u, 1 U2 1 1 10 u, 4 U2 S .P0119* INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00029012 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n KI M BALL ST Elgin 04:32 ® ❑ RELATED ®Y 0 N 05 21 2026 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill FT N E S W DUNDEEAVE COUNTY PROPERTY ❑ ® N DOORING® DOORING ❑y #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ❑V ® 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 ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEOAREA(S) FROPtf TOWED U1 0 Kell Pamela. K. 0 8 / yr 13-UNDER CARRIAGE ©,I !�. 2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0THER 0 U2 m F 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN - r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ii_6 I, 4 COM VEH 0 E! 1 0 ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 Z FP142335 IL 2026 REAR TELEPHONE IL D 0 KL77LH EP1 SC184471 Progressive ❑ IlN v U2 ni in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m EAN HOLDINGS LLC 977440380 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou m g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEON. 0 EWES 0 iiuv 0 i v 0 Dv yr ��j t2 ( E FIRE ❑ ® U2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X ❑Y 2i N DUNK VEH. AT CRASH 99-UNKNOWN Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 j( 4 COM VEH ❑ ® U1 CO FIRST CONTACT 2 7 .'_,_-5 *If Yes.See Sidebar ELGIN IL 60120 0 1 0 ER94026 IL 2026 I0 IL D 0 2C3CDXBG5J H232244 state farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Juarez.Juana 3138476sfp13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL) 2 3 10 / UI 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 05,21 /2026 04 32 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 28 18 05,21 ,2026 ❑pM 0 Construction R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 8 z J ❑AM ❑Maintenance U2 -a, ARREST NAME Kelly. Pamela. K. 11-601-Ax 1556000183 05/21 /2026 04 52 ICI pM SLMT 1 ® 11 4 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME • 0 UtilityPENDING o N t 2 El ARREST NAME 05/21 /2026 05 16 ®PM 0 Unknown work zone type U1 3O 2 2 3 ID ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30 1556-Sanchez.Jimena 301 302-Snow 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 truckrtrailer -< i- `-----I-----' N - r INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ,".(..! i (example:shuttle or charter bus):or 0 ti. 1 j J4- 1 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O I- L---------_J a....,µ. . } } . transporting employees In the course of their employment(example:employee transporter- y a van type L L.___a____� �� used or designated nated to transport betweeicle or n9andr 15 passengers,ssen rs,including the driver. C 1 - — — — .�, • } } • for direct compensation(example:large van used for specific purpose):or .rra..m .D L L--_-a • r - t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires u;ns F — — placarding(example:placards will be displayed on the vehicle). XI —1 — — — CARRIER NAME Z ADDRESS 0 D Not To Scale ( I I 0 I CITY/STATE/ZIP _ i. MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I . 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- ._._.; - USDOT NO. ILCC NO. rn XI Source of above Z NARRATIVE( 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 0 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ . 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