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HomeMy WebLinkAbout2026-00018914 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 101111111 lIII 1111110 11110111 H I11111100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004196983 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 4 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00018914 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn FLEETWOOD DR Elgin ® ❑ RELATED ❑Y ®N 04 07 2026 ®AM El YES E)NO U1 -< PRIVATE mo /day/yr 06:43 ❑PM FLOW CONDITION m ®1540!MI N E S © South McLean Blvd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 9 / yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 1E < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.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 s_iL 6 i COM VEH 0 Ea 1 I= FIRST CONTACT 1 7_;—_;__5 *IIYes.See Sidebar U1 0 Z FN97847 IL SOUTH ELGIN IL 60177 0 1 0 REAR TELEPHONE IL D JTHBK1GG2E2112708 Geico ❑Y ®N U2 r 1 R in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 4390-03-83-31 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 > Refused ❑Y ® N 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 NCv ❑DV CIRCLE NUMBER(S) U1 /2 0 0 7 Mazda 6 2008 Do-NONE 11_. t2 "_, DUE TO CRASH ❑ C 2 0 ®13-UNDER CARRIAGE o I 2 FIRE ID ® U2 C c F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 016•TOP 3 0 X ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i 6 1' 4 COM VEH ❑ ® U1 W FIRST CONTACT 10 Y._�_,-=5 •It Yes.See Sidebar C ELGIN IL 60123 0 1 0 EC97239 IL REAR 0 fp M IL D 1YVHP80C385M41489 State Farm ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Gomez.Omar. M. 1052433-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL) U2 m ##OCCS y P3 / / U1 1 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 41 ,12 /26 06 43 ®❑AM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 4 n T o", 2 0 2 99 + / ❑PM• ❑Construction * Z 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Martinez.Adrian 11-906 345000291 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility t 2 ❑ ARREST NAME AM T / / PM 0 Unknown work zone type 30 U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 345-Gomoll.Geoffrey 702 51 , 21 /026 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••--, , ; 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 -< INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ (example:shuttle or charter bus):or r r r X 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O I- <_---------i ` } I• I- transporting employees In the course of their employment(example:employee fi ..wl transporter-usually a van type vehicle or passenger car):or w L i.-----}----; - - c - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N / for direct compensation(example:large van used for specific purpose):or L L____a____. _ t i i _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)thatrequires 'D M ._®�y, 1 placarding(example:placards will be displayed on the vehicle). XI _unkz- _ _ _ _. D CARRIER NAME Z ADDRESS FIeeiwood?OrNs D rn o CITY/STATE/ZIP g Not To Scale 1 i.- i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. rTt 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 co LOCAL USE ONLY TRAILER VIN 2 m v 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. Z Red 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE