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HomeMy WebLinkAbout2026-00002690 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III III 11 IIII UH UU I IlU III If HH11fl DUOO DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X 111906 u, 1 U21 3 4 3 U1 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 11 U2 11 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 11 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202612026-00002690 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ❑Y ®N 01 14 2026 IMAM El YES ®NO U1 -< E ROUTE 20 Elgin PRIVATE mo /day/yr 11.32 ❑PM FLOW CONDITION ITT I 0 0/MI N E S © South McLean Blvd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 9 / yr Q 13-UNDER CARRIAGE 10 2 FIRE ❑ al < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 1T1 M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN I `Distraction Value ALGN FCITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST INTOONTACT 12 Y�L.S"1-I 5 CIOMs SeeSidaoarEH ❑ U,El 5 0 Z Carpentersville IL 60110 0 1 EY86558 IL 2025 REAR TELEPHONE IL D 1 FM H K7F8XBGA51398 First Chicago Insurance ❑v ®N U2 M 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Rivas Anomansin. Heidi.A. ILS 1275869-00 4 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES O NMv 0 NOV ❑DV /1 9 8 0 Chevrolet Equinox 2020' 00-NONE N_"j 12..-_t DUE TO CRASH p 2 x 0 13-UNDER CARRIAGE 10'( 2 FIRE ❑ ® U2 C c F 2 4 ❑Y El ❑ SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 9 X N UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 6 l:; COM VEH ❑ ® Ut CO FIRST CONTACT 7 O7 :_ _5 •IfYes.See Sidebar ELGIN IL 60124 0 1 CF24815 ILaR C 0 Si) IL D 3GNAXKEV4LL333445 Allstate ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same 912620028 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI j(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)r(TELEPHONE) (EMS) (HOSPITAL) 1 3 09 / :A / / UI 2 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 11 ,41 /026 11 32 ®❑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 Eri 2 0 11 1 11 99 1 ! 1 ❑PM- ❑Construction * N 3 0 11 1 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 -a, ARREST NAME / / ID PM ' o55N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT T 2 11 1 ARREST NAME AM T El / ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 55 345-Gomoll.Geoffrey 702 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 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 -< ` ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ErE.,Ra10„2 - (example:shuttle or charter bus):or 0 — 5 or fewer I- I- --I--•--I transporting mployeened to slin the course passengers thir emplod yment example:employeener X L ...l. 0 4.transporter �sedordesignated totransportbetween9a dr15r) ssen rs,includingthedriver. C } } } for direct compenation(example:large van used for specific purpose):or 0 ,-., L L""_"a-___. �'`! r < < < L 5 anyIs any vehdeused to transport hazardous material(HAZMAT)that requires ��. �� ^�� I placarding(example:placards will be isplayed on the vehicle). XI R I Z CARRIER NAME Z ADDRESS 0 T. Not To Scale I CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate 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. 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 Gray Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ti DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BYlT6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE