HomeMy WebLinkAbout2026-00045073 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202612026-00045073 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
S STATE ST El In05:15
® ❑ RELATED ®Y 0 N 07 27 2026 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W NATIONAL ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 16
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
CO 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 C)
0 6 !
yr 13-UNDER CARRIAGE IE
10 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 m
M 2 SY 15-OTHER
4 ❑Y El ❑UNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i,4 COM VEH 0 0 1 0
F. FIRST CONTACT 1 7 ;—_;__5 *Irves.See Sidebar Ut
Z Carpentersville IL 60110 0 1 0 CV47506 IL 2027 REAR
TELEPHONE
IL D 0 KN MAT2MV5J P516232 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
2 51 2 Same 2923699-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused El ® N 1 c
❑ DRIVER 0 PARKED 0 DRIVERLESS 0 PED N PEDAL 0 EWES 0 NMV 0 NCV 0 DV
Yr!2 0 0 3 Unknown Unknown 00-NONE 11_"j 12 -_t DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 2 FIRE 0 ® U2 C
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M 5 3 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
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-il 6 i1: COMVEH ❑ ® U1 CO
FIRST CONTACT 15 YA t.5 •IfYes.See Sidebar C
4 ELGIN IL 60123 B 1 0 REAR 0 Si)
IL D 0 NIA ❑y ❑N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
2 51 2 Same NIA BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused E Y°®N 9 u1 =
KNIT) (SEAT) (DOB) (SEX) {SAPT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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
N 1 ® 13 1 07,27 l2026 05 15 ®pm in a Work Zone? ®N DIRP co
I I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
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2 ❑ 2 99 + ! ❑PM• ❑Construction X
Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Ortiz.Aurelio 11-1002-A 1551000395 ! ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 ElARREST NAME 07 r 27 12026 05 15 ®PM ElUnknown work zone type U1 30
n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1551 Dede.Joseph 701 , 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
I0
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
- }-----I-----; I [... Not To Scat. combination):or
INDICATE NORTH p3
I �� — 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
' r r X
L L A ~ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
- — — —
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 ssen rs,includingthedriver,
C
} \ ^ } } for direct compensation(exam :large van used for specific purpose):or
L L--_-a-___. �ff I - i. < i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). m
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4% '► - —I
l CARRIER NAME
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[Waimea Ji. ADDRESS '0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I. -------- - USDOT NO. ILCC NO. rn
XI
Source of above Z
. 0 Yes II 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE