HomeMy WebLinkAbout2026-00036889 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets II
III H
IIII UHI
U
II III IlU
I III IflOOD
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004281W6
u, 9 U21 2 4 2 U1 3 U2 1 u,99 1_12 1 u,99 U2 1 5 15 u, 1 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202612026-00036889 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ®Y 0 N 06 25 2026 ®AM ❑YES ®NO U1 -<
ROYAL BLVD Elgin 00:28
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FTlMI N E S W FLETCHER DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
NAME(LAST,FIRST,M) Unknown.0. mo ! ! yr Ford Transit Connect 2020 00-NONE „ Oi_, DUE TOCRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.Top 3
9 9 ❑Y ❑N ID UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH 0 j$J 1 0
~ 0 9 FIRST CONTACT 12 7_: _-5 *II Yes.See&debar U1
Z 135755C IL 2026 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
1 FTBR1 C83LKA36313 unknown ❑Y ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same unknown 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'‘.3
RESPONDER 0
m
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NuV 0 e v 0 Dv
!1 9 9 1 Kia Motors Col ,orento 2012 00-NONE „ 12 _, DUE TO CRASH 0 ❑ 2 73
o - 13-UNDER CARRIAGE FIRE ID ElU2
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i 6 i'r-4 COM VEH ❑ ® u1 CO
F,,, FIRST CONTACT 10 Y��_,-=5 •(ryes,See Sidebar C
ELGIN IL 60123 0 1 0 FY94552 IL 2027 I 0
-1283 IL D 0 SXYKTDA2OCG217926 First Chicago ®Y ❑N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same I LS975267-03 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE, NUMBER 996 <
Refused Same u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 CO 11 9 06/25 l2026 00 28 ®❑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 �
0 2 23 28 ) ! ❑PM ❑Construction >F
1
Z3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
a1 ® 11 1 ARREST NAME Perez-PoI.Jose.A. 3-707 1518000622 / ! El PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
30
r 2 0 ARREST NAME AM
7 1 ! ❑❑PM 0 Unknown work zone type U1
2 lx 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 3O
1518-Versetto. Elisa 602 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 -<
` ` ' ' I r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
} I _ i (example:shuttle or charter bus):or C
I _ 0 } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
A
} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
LI 4. Is used or designated to transport between 9 and 15 passengers,including C}-----}----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
f placarding(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
ADDRESS 0
unr. 1 D
rn
II CITY/STATE/ZIP 0
g
Not To Scale - MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
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 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BYf O
DUE TO ® DISABLING DAMAGE Redmons VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE