HomeMy WebLinkAbout2026-00031585 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE I
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and f or Tow Due To Crash YR 202612026-00031585 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
W HIGHLAND AVE El In 07:30
® ❑ RELATED ®Y 0 N 05 30 2026 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo 1 day 1 yr ❑PM FLOW CONDITION m
FT N E S W STONEHAVEN DR COUNTY PROPERTY :IY ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) Kilbert. Rashad. D. 0 mo3 /
13-UNDER CARRIAGE 10 ' 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a 4 COIN VEH 0 j$J 1 00
1 0 1 0 FIRST CONTACT 12 7 ;1 _5 *IrYes.See Sidebar Ut
Z FR76408 IL 2026 Ismi
TELEPHONE
IL D 4T1 G 11 AK3RU841703 Progressive ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 959095744 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 Ncv 0 DV CIRCLE NUMBER(S) U1
yr 12 _ C1
o 13-UNDER CARRIAGE 10 1 c. 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 -
POINT OF s-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-5 C•IO e1sVEH See •Sidebar❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 15 1 Illinois Department of Natrual Resources 06,02 /2026 06 49 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1
v t 2 ❑ 1 NATURAL RESOURCES WAY 21 21 ! ! ❑AM ❑Construction *
ZJ 3 ❑ ❑CITATIONS ISSUED CI PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM '
o u1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
45
t 2 0 ARREST NAME AM
7 ! , ❑❑PM CI Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 567-Ramirez-Alvarado. Luis 901 337-Thompson , / ❑❑PM Workers present? ®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 -<
c ` -' -' r INDICATE NORTH combination):or —I
A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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(example:shuttle or charter bus):or 0
A - designed to carry 15 or fewer passengers and operated by a contract corner I O
} } } transporting employees in the course of their employment(example:employee X
rter-
y a van type vehicle or
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i. <____a____� / 42lsuosedordesllnatedto transport between9a dr15passengers,includirgthedriver,
/ I. } } for direct compensation(example:large van used for speific purose):or
____a _�___ — — - �O i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequiresplacarding(example:placards will be displayed on the vehicle). XI
_ CARRIER NAME Z
ADDRESS 0
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Not To Scale i CITY/STATE/ZIP 0
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MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
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_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE