HomeMy WebLinkAbout2026-00055213 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00055213 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ❑Y ®N 09 11 2026 ®AM ❑YES ®NO U1 -<
E CHICAGO ST Elgin07:03
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W N LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 co
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
lyi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 la uv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
f'1T_ TOWED EN
U1 0Guerrero De Jesus. Luis. R. Chevrolet Silverado 2014 00-NONE Q �i 0OUETOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
10.
15-OTHER
M 2 4 El ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�B 4 COM VEH 0 Ea 3 0
F. FIRST CONTACT 12 7 ;—, _5 *IIYes.See Sidebar U1
Z Gilberts IL 60136 0 1 0 3677826B IL 2027 REAR
TELEPHONE
IL D 0 3GCUKREC7EG361179 State Farm ❑Y ®N U2 Mr—
St
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 0501719-SFP-13 1 1—
'6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ® N 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O uv 0 KCv 0 Dv CIRCLE NUMBER(S) U1
yr Chevrolet Traverse 2010' Do-NONE O1 0i.O DUE TO CRASH 0 2
0 13-UNDER CARRIAGE 10 1. 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s I 4- 5 1',_
COM VEH_{_O ._5 •(ryes,See Sidebar
D ® U1 CO
PINGREE GROVE FIRST CONTACT 6 Y_i IL 60140 9160 0 1 0 Z123865 IL 2027 AR
IL D 0 1 G N LVH ED3AJ224875 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0959927-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 91 , 11 l026 07 04 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
;, 2 ❑ 11 1 28 99
! , ❑PM, ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a ® 11 1 ARREST NAME Guerrero De Jesus. Luis• R. 11-601 1575000055 / / ID Pm SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM U1 30
t 2 0 11 1 ARREST NAME 91 111 1026 07 04 [M PM ❑Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1575-Williamson.Colin 302 275-Engelke 10 , 61 ,026 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 .Z-1
IL
.. A, 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ J -1 _ i. e. ,. (example:shuttle or charter bus):or
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. , " 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
�,tt.�unitz—unrta� } } } 9 Po Pa 9e to
for direct compensation(example:large van used for specific purpose):or SEBCZOIKB O
L %.
' L_._-a..... - i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
i
m
pWcartling(example:placards will be displayed on the vehicle). �,-- 1=:?Chi�oo?Stiert D
... .....
Not7To7Scele CARRIER NAME 0
1 Z
ADDRESS 0
T.
/ C)
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;....Y. ._.; - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No.
XI
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 M
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
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
Gray Silver
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