HomeMy WebLinkAbout2026-00033544 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
IIIIII II 111111 IIIIIIIII III IIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00427BO
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INVESTIGATING AGENCY DAMAGE TO ANY El 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 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00033544 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ®Y 0 N 06 11 2026 ❑AM ❑YES ®NO U1 -<
N GROVE AVE I KIMBALL ST Elgin mo /day/yr 05:52 ®PM FLOW CONDITION m
1�5 ®/MI N E O W N GROVE AVE I KIMBALL ST COUNTY PROPERTY ❑Y Ig,I N DOORING ❑y #OF MOTOR ❑SLOW 15 -I
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
0 4 /
yr 2016 13-UNDER CARRIAGE 1U 1 • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
F 2 5 ❑Y ® is-OTHER
SYSTEM
❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it S 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60120 B 1 0 FIRST CONTACT 12 7 ; __5 *II Yes.See Sidebar U1
Z DW43728 I L 2027
TELEPHONE
IL D 0 J M 1 DKBD77G0125716 State Farm ❑Y Il N U2 M
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 0148145-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑New 0 KOV ❑DV CIRCLE NUMBER(S) U1
2 0 0 8 Honda CRV 2001 00-NONE 0. Q!'0DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C
c
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 �.i,_4 COM VEH ❑ ® U1 Co
FIRST CONTACT 12 7� , .5 •If Yes.See SidebarC
H E LG I N IL 60123 B 1 0 GC73394 IL 2026 I0 Si)
M
IL D 0 JHLRD187715021763 None ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same None BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPOND 0 N U1 =
(UNIT) (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 ❑Y U2 Z
N 1 ® 11 1 06,11 /2026 05 53 ®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 El AM U1
v 2 0 2 25 06,11 ,2026 05 55 ®PM ❑Construction >F
R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
- ®a, ARREST NAME CAULFIELD, NICOLE, K. 11-902 476000460 06/11 /2026 05 58 Igi pM
o1 • SLMT
U 11 1 El CITATIONS ISSUED 0 PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME
AM• 0 Utility
30
t 2 ❑ 1 1 1 ARREST NAME VASQUEZ PEREZ,Aldan,J. 3-707 476000461 06,1 1 /2026 06 33 ®PM ❑Unknown work zone type U1
2 2 3 ❑ca
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
476-Ramos,Clarissa 102 337-Thompson 07 ,21 ,2026 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r•---, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
INDICATE NORTH p1
BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driverC
uiws - } (example:shuttle or charter bus):or
0
` r r 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
}----A----i r
L 5
J � _ - transporting employees in the course of their employment� (example:employee � X
y a van type
< ...I. — — — \��_ — 4.transporter
�sedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,includingthedrrver. C
/g,�$ 1 I. } } • •
for direct compensation(examp large van used for specific purpose):or
' L.._-a-___� l' ro,,t l - } I. I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
- - - rump placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
1 I ADDRESS
C)
CITY/STATE/ZIP g
Not To Scale J _ i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Red Gold
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE