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HomeMy WebLinkAbout2026-00032415 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI UU I� III fl11 11UU 1 1 HH1OO DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004259527 u, 1 U21 1 1 1 U, 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* 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-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00032415 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 06 06 2026 ®AM ❑YES ®NO U1 N LIBERTY ST Elgin10:34 _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m ®!MI N E S W n liberty St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn O WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FTtOntr TOWED DI E U1 0Perez Gutierrez. Marian el Toyota Prius 2005 00-NONE • 2DUE TO CRASH ❑ NAME(LAST,FIRST,M) g mo yr 13-UNDER CARRIAGE ©it),I 0,:0 FIRE 2 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SYTM IN ENGAGED4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_;1 _5 *lives.See Sidebar U1 Z FY77825 IL 2026 REAR TELEPHONE IL D 0 JTDKB20U853032024 First Chicago Insurance C ❑Y Igl N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Mariangel Perez Guti,Jose Maldo 1222800-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 73 m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEO ❑PEDAL 0 EWES ❑NIAV 0 Ncv ❑Dv CIRCLE NUMBER(S) U1 /2 0 0 2 Honda Civic 2025 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑YNi N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ El Ui CO I— FIRST CONTACT 6 O7 a_Q)OS •If Yes,See Sidebar C Z Carpentersville IL 60110 0 1 0 SC22208 IL 2026aR 0 fn D IL D 0 2HGFE4F80SH316126 Farmers Insurance ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 547828203 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 0 Y U2 Z N 1 ® 11 1 06/06 /2026 10 34 ®❑pM 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 C) 0 2 ❑ 28 03 / / ❑PM ❑Construction * R 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Perez Gutierrez, Mariangel 11-601-Ax W1566000080 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility r 2 ❑ 30 ARREST NAME AM 7 / / pM El Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 30 1566 Polo�in, Matthew 300 / / ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 ..._... . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or c0 < <.__-a-_-_- , l• < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-..:__ ; t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z ADDRESS 0 T. , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 .----4-----4 ,--- -Y- ; ; , ; USDOT NO. ILCC NO. m 73 Source of above z . -I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own 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' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Green Black 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE