HomeMy WebLinkAbout2026-00055125 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 ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00055125 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN STATE ST El In 05:09
® ❑ RELATED ®Y 0 N 09 10 2026 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION 1T1
FT!MI N E S W FRAZIER AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
1 0 !
yr 13-UNDER CARRIAGE 1U IE
1 !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 M
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN x
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i, a �i,4 COM VEH 0 j$J 1 n
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 7 O7 _; -_--5 *If Yes.See Sidebar U1 0
Z FS95977 IL 2027 REAR
TELEPHONE
IL D 0 1 V2LR2CAOKC514904 Progressive ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 866656519 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 23N 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 INAV 0 Ncv ❑Dv
yr Chevrolet Silverado 2016 DO-NONE 00i.O DUE TO CRASH ❑ 2
o 13-UNDER CARRIAGE 10,i l.. 2 FIRE ID El U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istract on Value 9 0
s I I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 B COM VEH ❑ ® U1 CO
ZCRYSTAL *
CRYSTAL LAKE Y -5 )ryes.See Sidebar C IL 60014 0 1 0 1957555B IL 2027 Si)0
D
IL D 0 3GCUKREC3GG292154 AMERIASURE INSURANCE COMP ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
1 99 9 PARKWAY FORMING INC- CA20258781902 BAc $
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 08 /
UI 1 D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 09,10 /2026 09 10 ®❑AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
T
0 2 ❑ 2 23 , ! ❑PM ❑Construction *
Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME SANGS.ANIAH.J. 11-902 1571-000057 / ! ❑PM
® 1 1 4 Utilit SLMT
o N 1 SECTION CITATION NO. ROAD CLEARANCE TIME Ely
❑CITATIONS ISSUED PENDING
r 2 ❑ ARREST NAME 09/10 12026 05 09 ®PM El Unknown work zone type U1 0 AM
LO
45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 45
1571-Rosas-Pereyra.Gerardo 501 10 , 13,2026 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 INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I I _ (example:shuttle or charter bus):or
Not To Scale I '
N 3. Is tlesgnetl to car 15 or fewerftheir passengers
and operated a contract career O
} } } transporting employees In the course of thir employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
LLT 4. Is used or designated to transport between 9 and 15 passengers,including C------;----; ,,,�, - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
L L____a____� ray t i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
'D
placarding(example:placards will be displayed on the vehicle). XI
r - —1
- CARRIER NAME Z
(."'°°nee.) r 0
' ADDRESS D
r 0
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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
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
Black Blue
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE