HomeMy WebLinkAbout2026-00037006 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00037006 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 06 25 2026 ❑AM ❑YES ®NO U1 —<
SHALES PKWY Elgin01:42
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W BODE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 3 Cl)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
0 4 /
yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 3 M
M 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 �i COM VEH 0 j$J 1 0
F. ELGIN N I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1
Z X911064 IL 26 ' E
TELEPHONE
IL D 0 2T1 KR30E08C709766 Allstate ®v 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 912435587 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑iiuv 0 NCv ❑Dv
yr 12
o 13-UNDER CARRIAGE 10,i• 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 U1 0
POINT OF 8 I 4 COM VEH ❑ ® CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _ 6 l:' C
FIRST CONTACT 1 7� _,__5 •IfYes,See Sidebar
— Hampshire IL 60140 0 1 0 DZ74889 IL 2026 I 0Si)
IL D 0 5TDZA23C14S155973 Ameican Freedom ❑Y ®N RDEF ZI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 12Z513056-00 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O 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 0 Y U2 Z
U 1 ® 11 1 06,25 /2026 01 42 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 1 3 2 06 06,25 ,2026 01 42 PM
® • ❑Construction >E
1 4
R 3 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
J ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Castillo.Coromoto.J. 11-1204-B 15710008 06/25/2026 01 48 ®PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
0 AM
r 2 0 ARREST NAME 06/25 /2026 02 10 ®PM 0 Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1571-Rosas-Pereyra.Gerardo 302 07 , 14,2026 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 truck trailer -<
;.---_r----; or 1 - combination):
Not To Scale 1 INDICATE NORTH p0
(70 i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
5 or fewer
< <---- -•-•; I i I transporting mployeened to slin the course passengers thir emplod yment example:employee
transporter} } }
-usually a van type vehicle or passenger car):orCD
L }-----}----l. - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or
L L____a____. - - - - - - _ t I I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires 71
( I - placarding(example:placards will be displayed on the vehicle). m
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t 1'I (� . . . . CARRIER NAME Z
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ADDRESS 'Z
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CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes 0 No ❑ Unknown A
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'; 0 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE