HomeMy WebLinkAbout2026-00050455 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ElOVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00050455 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME
WALNUT AVE 1 ELM ST Elgin SECONDARY CRASH 15
® ❑ RELATED ®Y ❑N 08 21 2026 ®AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 06:25 ❑PM FLOW CONDITION M
010 0/MI NOS S W walnut avelelm St COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Perez. Debra. D. 1 0 /
yr 13-UNDER CARRIAGE I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 2 rr1
F 2 4 ❑Y ®SNEM❑ n 15-OTHER
UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�a �i COM VEH ❑ j$J 1 0
I . ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1
ZEU93301 IL 2026 REAR
TELEPHONE
IL D 0 3CZRU6H73NM741225 Statefarm Insurance ®Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 2618405-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 N4v 0 NCv ❑DV
/1 9 8 0 Honda Pilot 2026 00-NONE O, Qj.O DUETOCRASH rg D 2 x
... 13-UNDER CARRIAGE FIRE ❑ ® U2 C
il
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,19-TOP 3 X
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 i;.-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7'. .5 •If Yes.See SidebarC
Z SOUTH ELGIN IL 60177 0 1 0 FX IL 2026 I 0
M
IL D 0 7FARS6H89TE109954 Statefarm Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire Torres-Lara.Juan. D. 3528461-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
W /
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#OCCS D
7)
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 08/21 /2026 06 25 ®❑PM 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 C)
v 2 0 2 14 08/21 /2026 06 28 ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
®AM ❑Maintenance U2
4 1 ® 11 4 ARREST NAME Perez. Debra. D. 3-707 470000183 08/21 /2026 08 35 ❑pM SLMT
B!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility
r 2 0 ARREST NAME Perez. Debra. D. 11-902 470000182 08/21 /2026 07 00 MPM 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
470-Berumen. Brian 701 275-Engelke 10 /06/2026 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.
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 -<
c ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
L '�` r 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
- } } I-
. transporting employees In the course of their employment(example:employee
ilkj �';,r Ntransporter-usually a van type vehicle or passenger car):or c0
L 4. Is used or desi nated to trans rt between 9 and 15 ge ng C
}--- ----; ''r - } } } g Po passen rs,indudi [he driver,
- for direct compensation(example:large van used for specific purpose):or O
I I S I �_'__ I
L i.____a____.:. Qo,. u+ea— — — _ t i I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
Will1°°"s CARRIER NAME
_ ADDRESS 'O
D
rn
Not TO Scale 1 CITYISTATElZIP n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
Xl
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
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
Silver Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE