HomeMy WebLinkAbout2026-00030310 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII
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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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2026I 2026-0003031 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 8 m® ❑ RELATED PRIVATE ❑Y ®N 05 27 2026 ❑AM ❑YES ®NO U1 -<
RT20 EB Elgin mo /day/yr 12:44 ®PM FLOW CONDITION M_
q0(y� COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR IR SLOW 1 (n
IXI_ YJ!MI N E S W State St WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
(g)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
FOR DAMAGEDAREA(S) FRObir TOWED U1 00 6 /
13-UNDER CARRIAGE 10 , 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<I1
M 2 SY4 ❑Y ®SNEM DUNK VEH. 0 AT CRASH IN 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :il a 4 COM VEH ® ❑ 1 0
H 1- Horn Lake MS 386370 0 1 0 FIRST CONTACT 12 r ; _5 *IfYes.SeeSidebar U,
ZV7691HY MS 2026
TELEPHONE
MS A 7 1XKYD49XONJ145043 Technology Insurance ❑Y Il N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1
Perimeter Transporta TMC1725900-01 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 uv 0 QV 0 Dv
9 8 9 Kia Motors Co�ptima 2020' 00-NONE 11_"j t2--_, DUETO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10;1 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 I 6 .!,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 7 •-�-_5 •(ryes,See Sidebar C
Z STREAMWOOD IL 60107 0 1 0 CC87307 IL 2026 FIRST
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IL D 0 5XXGU4L14LG443964 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 996679805 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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(27 /2026 12 44 ®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 C)
0
1
2 0 03 18 ( ( ❑PM ®Construction *
•
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a1El 11 1 ARREST NAME Johnson. Derrick. L. 11-601-Ax 486000282 ( r El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 ❑ ARREST NAMEAM
7 ( / ❑❑PM 0 Unknown work zone type 50
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 50
486-Munoz.Jasmine 701 - 1 / ❑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----; INDICATE NORTH combination):or
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ }
` (example:shuttle or charter bus):or
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3. Is designed to carry15 or fewer passengers and operated a contract career O
} } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CC
OL }-----}----; �nvrm - } 4. Is used or designated to transport between 9 and 1 passengers,including the driver,
} 1. 4.
direct compensation(example:large van used fors specific purpose):or
L L----a-- - l. i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Perimeter Transportation Z
ADDRESS 5515 E HOLMES RD z
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CITY/STATE/ZIP Memphis 1 TN 138118 o
L Not To Scale 1 m
MOTOR CARR.ID El Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
i----------1 - USDOT NO. 577861 ILCC NO. m
XI
Source of above z
. Form Number
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IDOT PERMIT NO. 577861 WIDELOAD' 0 Yes ®No =
TRAILER VIN 1 1JJV532D2RL433069 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ M Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 65 ft. 2 ft. w
White Black
U 1 TOWED TOTAL VEHICLE LENGTH 65 F ft. NO.OF AXLES 5
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. 2 CARGO BODY TYPE 9 LOAD TYPE 5