HomeMy WebLinkAbout2026-00008104 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III III 11 IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ® 6 Injury and for Tow Due To Crash YR 202612026-00008104 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
1180 S RANDALL RD Elgin02:09
® ❑ RELATED ❑Y ®N 02 11 2026 ❑AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ❑SLOW Cl)
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Del Mundo. Isabelita. R. 1 1 /
yr 13-UNDER CARRIAGE 10 !:. 2 FIRE ❑ alC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED ❑ 0 U2 1T1
F 2 8
❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�a 4 COM VEH 0 Ea 4 0
0
I= FH68794 IL FIRST CONTACT 12 7 ;—, _5 *IIYes.See Sidebar Ut
Z SOUTH ELGIN IL 60177 B 4 0 REAR
TELEPHONE
IL D KM8HBCAB9RU148339 Progressive Insurance El ignq U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Elgin Fire Same 860699265 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr 12 _ 71
o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlonvalue U1 3 -
POINT OF s-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�=1-.:-5 COM•I sVEH See •Sidebar❑ 0
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CO
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEATI (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
W 03 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 1 Sparkle Express Car Wash Cinder Block Wall 02,11 /2026 02 09 ®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
a- 2 0 2 1 1180 S RANDALL RD ELGIN IL 60123 10 99
! ! ❑PM• ❑Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM '
o N 1 0 •
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 00
SLMT
t 2 0 ARREST NAME AM
7 ! 1 ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
-2 3 0 ❑AM Workers present? 0
345-Gomoll.Geoffrey 801 ! / ❑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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} e - i (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
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- } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L I-----}----; ' - I. } } } •4. Is used or designated to transport between 9 and 1 passengers,including the driver, to
for direct compensation(example:large van used fors specific purpose):or
I _ L i. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME -I
Z
. .4_fa?:., _ ADDRESS 0
D
No!7b Scale i w
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"---- "1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE