HomeMy WebLinkAbout2026-00040776 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004298386
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INVESTIGATING AGENCY DAMAGE TO ANY 215500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00040776 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
822 SUMMIT ST EIIn 05:21
® ❑ RELATED ❑Y ®N 07 08 2026 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 '
❑ FT/MI NESW Cook HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N OO C)
0 3 /
yr 13-UNDER CARRIAGE CR
1a l !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 00 1fi
F 2 4 SY15-OTHER
❑Y ®N SE❑UNK VEH. 0 ATCRASHM IND 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 5 ALGN 2
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iII 6 ii,4 COM VEH ❑ j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 6 7_±.—--5 *If Yes.See Sidebar Ut
ZEF74329 IL 2027 E
TELEPHONE
IL D 0 WAUML44E45N004291 Country Financial ®Y 0 N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same PO10623378 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused 0 Y ® N 2XI
m g DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 Nuy 0 NOV ❑Dv CIRCLE NUMBER(S) U1
/1 9 6 7 Cadillac SRX 2013 Do-NONE ,._"i t2..-_, DUETO CRASH ❑ cg 2 x
0 13-UNDER CARRIAGE 10 1 2 FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
POINT OF s iI 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - all'._
FIRST CONTACT 6 Y__{_ s•_5 •IfYes,SeeSidebar
— Elgin IL 60120 0 1 0 AR36111 IL 2027 REAR
0 N
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IL D 0 3GYFNG E3XDS630642 AllState ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 966578793 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL)
1 3 01 /
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 5 07,08 /2026 05 21 ®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 ❑AM U1
0 2 ❑ 30 41 / / ❑PM ❑Construction *
7
Z 3 ❑ gi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Ramirez.Cesar 3-707 1565000071 / / El PM SLMT
o u ® 11 ElCITATIONS •ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
00
t 2 ARREST NAME AM
7 El / ❑❑PM El Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 00
1565-Harris.Jeffrey 201 337-Thompson 08 , 11 ,2026 01 30 ❑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
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( 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
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3. Is
. L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } 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 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE