HomeMy WebLinkAbout2026-00037577 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IIII Mil U II III lI10D 11111111111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 El ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00037577 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
1156 DUNDEE AVE Elgin06:00
® ❑ RELATED ❑Y ®N 06 27 2026 DAM ❑YES ®NO U1
_ _ PRIVATE mo /day!yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) .FROM TOWED U1 0
Unknown.O. Chevrolet Traverse 2014 00-NONE 11_ 12 `_� DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10l ! 2 FIRE 0 M <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 r11
9 9 SYSTEM IN O ENGAGED 0 15-OTHER p9 16-TOP 3 ' _
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 �i 4 COM VEH ❑ j$J 1 0
F� 0 9 FIRST CONTACT 9 7 : __5 *lIVes.SeeSidebar U1
Z EQ38443 IL 2026 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
1GNKRFEDXEJ224317 Uknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m/v 0 KCV 0 DV
yr Honda Civic 2026 00-NONE 111 12 (,-2 FIRE DUE o CRASH 0❑ ® U2 2 C
13-UNDER CARRIAGE
v AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10' DISTRACTED 0 ® SPDR 0
SEX SAFT AIR 9!16-TOPO3 * 0
SYSTEM IN ENGAGED 15-OTHER
a ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN 0istracton Value 0
POINT OF 8 4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 j',_ COM VEH ❑ ® CO
FIRST CONTACT 3 7_ _,-_5 •• •It Yes,See Sidebar
H FT41545 IL 2026 I 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2HGFE2F21TH565178 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Bridges.Serenity.J. 3399566SFP13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT( (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 03 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 9 06,27 /2026 07 09 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 30 30
N 3 ❑ CITATIONS ISSUED 0 PENDING + ! ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
-a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
99
t 2 D ARREST NAME AM
T 1 / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 99
567-Ramirez-Alvarado. Luis 102 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 ----r••--, , % A CMV is defined as any motor vehicle used to transport passengers or property and: Z
A1. Hasatlon fight ht rating more than 10,000 pounds(example
:truck or truck trailer -<
` ' ' I r INDICATE NORTH p1
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. _ } (example:shuttle or charter bus):or
L A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
t C
}--- ----+ - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
1 for direct compensation(example:large van used for specifi purpo
se):ose):or
4O
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__ _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle).
T.
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CARRIER NAME
ADDRESS 0C)
CITY/STATE/ZIP g
Not To Scale MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
%"-------4. - % % % % USDOT NO. ILCC NO. m
XI
Source of above z
. 0 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-; ❑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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black 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