HomeMy WebLinkAbout2026-00014062 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 1001111010I 11111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 0416 8141•
u, 1 U21 1 1 1 u, 8 U2 1 u, 1 u2 1 u, 1 U2 1 1 12 u, 13 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 I3l ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00014062 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 03 13 2026 ®AM ❑YES ®NO U1 -<
S RANDALL RD Elgin10:58
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
FT N E S W WELD RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Thakkar. Harish. P. 1 0 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ga U2 M
M 2 4 ❑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 it 6 li 4 COM VEH ❑ Ea 1 0
I`• 60110 0 1 0 FIRST CONTACT 7 O7 _; ---5 *If Yes,See Sidebar U1 0
Z 96310EL IL ' E
TELEPHONE
IL D 7SAYGDEEORA288823 State Farm ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0184348-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
m �{ DElVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAv 0 Ncv 0 DV
yr 12
0 13-UNDER CARRIAGE to 2 FIRE ❑ ® U2 C
c
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 916•Top
3 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value
POINT OF 8 I 4 COM VEH D ® ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _ 6 l' C
FIRST CONTACT 1 7�._, _-5 •IfYes.See Sidebar
Z GILBERTS IL 60136 0 1 0 2050714B IL I 0 Si)
IL D 1 GCSKZCG5GZ413227 Foremost Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
O'Brien Custom Homes A7992600500 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB( (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE! (EMS) (HOSPITAL)
1 3 11 / F 2 3 0 1
m
/ / #OCCS D
71
/ / 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
u 1 ® 11 1 31 ,31 ,026 10 58 ®❑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 C)
o"
2 20 99 1 1 0 PM El Construction
*
Z 1 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o1 ® 11 1 ARREST NAME Thakkar. Harish. P. 11-709-A 345000286 ! ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
45
f 2 ARREST NAME AM
1 r ❑❑
7 PM 0 Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
345-Gomoll.Geoffrey 801 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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or -I
unit 2 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I } (example:shuttle or charter bus):or 0
Initlal lno?Pot?f7lmpad I 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I 0
- fit I } } } transporting employees in the course of their employment(example:employee X
< <. _A. .�
'. \\ transporter-usually a van type vehicle or passenger car):or CO
C
L }-----}----; - } } •4. Is used or designated to transport between 9 and 1 passen passengers,including the driver,
II,
� for direct compensation(example:large van used for specific purpose):or
. . . I o
-- -a-...1 uoftl i - t i } i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
piacarding(example:placards will be displayed on the vehicle).
;0
D
�- CARRIER NAME Z
Weld?Roed ADDRESS O
w
Not To Scale l CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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
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
Black 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