HomeMy WebLinkAbout2026-00032154 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XG04259358
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202612026-00032154 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
424 G EORG E ST El In02:07
® ❑ RELATED ❑Y ®N 06 05 2026 IgiAM El YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W 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
g DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q
Unknown.0. Unknown Unknown 00-NONE 11,• 12 OUETOCRASH ❑ EN E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 2 <
9 3 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 0 ' _
❑Y ❑N El UNK VEH. AT CRASH 99-UNKNOWN `Detraction Value ALGN
6 4 COM VEH ❑ Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1�6 � ,_ 1 0
~ 0 1 0 FIRST CONTACT I 7_; _5 *lI Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unkown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 DV
yr Nissan Murano 2022 00-NONE 11 .12.._, DUE TO CRASH ❑ ® 1 ,'t/
o 13-UNDERCARRIAGE FIRE ❑ El U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0
a SYSTEM IN 9 ENGAGED 9 15-OTHER ()IS-TOP 3 ❑ ® SPDR n
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value U1 9 -
POINT OF 6 I -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 i'_ COM VEH ❑ ® CO
F,,, FIRST CONTACT 9 7 , _6 C.
If Yes.See Sidebar
EP56222 IL 2026 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5N1AZ2BS3NC127038 Kemper ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Cirar. Bernadette. R. 12A0001486090 BAc $
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)1{ADDRESS)1ITELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 06 105 l2026 02 27 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 20 99
N 3 0 ❑CITATIONS ISSUED ID PENDING + ! ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME / / ID PM '
o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2ARREST NAME AM
T El1 r ❑❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID - ❑AM Workers present? ❑Y 30
1522-Velazquez. Noeli 401 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 e---•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 -<
} }---------- u�m, A. - r INDICATE ARROW NORTH
combination):or
—I
N2 Is used or designed to transport more than 15 passengers including the driver C
f:'i C)
1 _ } (example:shuttle or charter bus):or
'<< 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier I O
I- }____A____; as •a� - } } } transportinggemployees in thecoursee of their employment
\ p ypbymar):or(example:employee co
u�z transporter-usually a van type vehicle or passenger car):or co
' . 4. Is used or designated to transport between 9 and 15 passengers,including cC/t
}--- ----+ - •} } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
O
__ _ i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
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ADDRESS
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CITY/STATE/ZIP g
Not To Scale MOTOR CARR.ID 0 Interstate 0 Intrastate
I ° Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 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. CARGO BODY TYPE LOAD TYPE