HomeMy WebLinkAbout2026-00027154 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets _ 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 13
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202612026-00027154 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 05 13 2026 ®AM ❑YES ®NO U1 -<
815 S RANDALL RD Elgin11:88
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
5 !MI N E S VY Randall RdlColle a Green Dr COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR 0 SLOW 1 (n
0 g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 3 /
yr 13-UNDER CARRIAGE 10:) 2 : 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 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 6 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 4 COM VEH 0 Ea 5
H 1 E LG I N IL 60123 0 1 0 E754437 IL FIRST CONTACT 12 7 ;Isui
_s Yes.See Sidebar Ut 0
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TELEPHONE
IL D 3FAH P08Z48R202259 Progressive ❑Y ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Tirado.Jacqueline 993068841 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 eu
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMV 0 NCv ❑ CIRCLE NUMBER(S) U1
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2 0 0 6 Tesla Model 3 2022 00-NONE ,�_-1 12..-_, DUETO CRASH ❑ C 2
oYr 13-UNDERCARRIAGE ta;l 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 0 X
❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value
POINT OF 6 II 4 COM VEH ❑ ® Ut W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 6 1',_
FIRST CONTACT 6 Y :j= _s •If Yes.See Sidebar C
= Rockford IL 61114 0 1 0 EK23582 IL aR0 N
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IL D 5YJ3E1EA6NF369363 None ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same N/A BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 05,13 i2O26 11 38 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
Si 2 0 03 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING + / ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 8
-a, ARREST NAME / / ID PM '
o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
00
T 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 00
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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. . ..._- - . transporting edmployeeslin5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
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
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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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Blue.Dark
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE