HomeMy WebLinkAbout2026-00005102 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
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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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00005102 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 01 27 2026 ®AM ❑YES ®NO U1
S MCLEAN BLVD Elgin mo /day/yr 07:44 ❑PM FLOW CONDITION m
®50 ® O COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR El SLOW 3 Cl)
!MI N E S W Van St WITH VEHICLES INVLD IN STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 6 /
Toyota Camry 2025 00-NONE „_ O i-, DUE TO CRASH 0 13-UNDER CARRIAGE 10 : 2 FIRE 0 ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_i L a COM VEH 0 Ea 1 O
4
ZE LG I N IL 60123 0 1 0 FC35519 IL FIRST CONTACT 12 7 : __s Yes.See Sidebar Ut
TELEPHONE
IL D 4T1 DBADK6SU523043 State Farm ❑Y ❑N U2 Ill . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑
1 9 yf 2 Honda Odyssey 2005 00-NONE 1i_-I 12--_, DUETO CRASH ❑ C 2
o - 13-UNDERCARRIAGE 10,i 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 6 4 COM VEH ❑ ® ut CO
FIRST CONTACT 6 O7 !lay._
Q;I�-__ IfYes.See Sidebar s •
ELGIN IL 60123 0 1 0 Y762174 IL IZFaR C
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D
IL D 5FNRL38435B029587 Progressive Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 867479953 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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
N 1 ® 11 1 01 ,27 r2026 07 44 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 03 99 , r ❑PM ❑Construction *
Z 3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Nava. Eni 11-601 345000277 r r ❑PM SLMT '
o N iffi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM 30
t 2 ElARREST NAME Nava. Eni 3-707 345000278 r r 0 pM ElUnknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
345-Gomoll.Geoffrey 602 03 , 10,2026 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••--, , unit t ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i I.i I I ; 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
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} }---_r__--; ; } combination):or —I
n meant
INDICATE NORTH C
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BY ARROW 2 Is used or designed to transport mOre than 15 C
i_ 4 1 I y I ,. ,. ,. (example:shuttle or charter bus):or � rs mcluding the driver 0
5$s
3. Is desgned to car 15 or fewer passengers and operated a contract carrier O
- trwry } } } transporting employees in the course of their employment(example:employee X
RI transporter-usually a van type vehicle or passenger car):or co} } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
for direct compensation(example:large van used for specific purpose):or O
L i le--le-- i. < i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 71
I I I placarding(example:placards will be displayed on the vehicle). m,Zj
—1
Van?Street CARRIER NAME Z
ADDRESS 0
D
C)
I CITY/STATE/ZIP
0
g
I I - MOTOR CARR.ID 0 Interstate 0 Intrastate 5
Not To Scale 1 ❑ Not in Comm./Govt. Not in Comm./Other
❑ 00
:- .------ --; I I USDOT NO. ILCC NO. C
XI
Source of above
result.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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 E
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Blue
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