HomeMy WebLinkAbout2026-00055393 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 ❑ 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 ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00055393 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 71
® ❑ RELATED PRIVATE 0 Y ®N 09 11 2026 ❑AM ❑YES ®NO U1 -<
N MCLEAN BLVD Elgin mo /day/yr 08 49 ®PM FLOW CONDITION m
05 1C.'J/MI N E O W BIGTI M BER Rd COUNTY PROPERTY El PROPERTY ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS Eg PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) BUNCH. KELVIN. L. mo yr 0-NONE 11_
13-UNDER CARRIAGE 10 i 12 ` , DUE TO CRASH ❑ VI E
2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i L 6 4 COM VEH 0 Ea 1
~ ELGIN IL 60123 A 1 0 FIRST CONTACT 00 7_; _5 *II Yes.See Sidebar Ut
0
REAR
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TELEPHONE
IL D 0 ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
Sherman RESPONDER
9 eu^
p; DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 DV
9 9 9 Jeep(after 19681�rokee 2016', 00-NONE 1("j 12..-_, DUETOCRASH ❑ !g 2 x
o Yr 13-UNDER CARRIAGE 1 FIRE ❑ ® U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracuon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 ij:, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar
= ELGINREAR
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Mz IL 60123 0 1 0 FH22842 IL 2027
IL D 0 1 C4PJ MCS7GW213891 ALLSTATE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 2030287215 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (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 0 Y U2 Z
N 1 ® 12 1 09,11 ,2026 08 49 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 2 99 09,11 ,2026 08 04 ®PM ❑Construction *
1
R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME BUNCH. KELVIN. L. 11-1003 1571000058 09/11 /2026 08 56 ®PM SLMT
o U1 ® 0 ❑Utilit 12 CITATIONS ISSUED PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME y
r 2 ❑ ARREST NAME 09(1 1 /2026 09 20 0 PM 0 Unknown work zone type 0 AM U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 45
1571-Rosas-Pereyra.Gerardo 501 , / ❑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
r i ADDITIONAL UNITS FORMS.
r ----r••--, , I I - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
II 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} } ' ' j I '. I - I. INDICATE NORTH combination):or -I
p3
` BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
- — — — — r- -- - - - T,
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
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} } I. transporting employee � �In the course of their employment(example:employee � �
r 1 transporter-usually a van type vehicle or passenger car):or w
L L.___a__ - - - - - 4. Is used ordesi natedtotrans rtbetween9and 15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
L L--_-a-...� - " - t i. I ,_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
ti 1 placarding(example:placards will be displayed on the vehicle). ;p
nrot TO scare 1 N D
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CARRIER NAME Z
ADDRESS 'n
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CITY/STATE/ZIP g
o� - 1 MOTOR CARR.ID ❑ Interstate ❑ Intrastate
1 I r ❑ Not in Comm./Govt. Not in Comm./Other
; _Y_ _.. 4t1 r r r r -;
USDOT NO. ILCC NO. m
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Source of above z
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Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE