HomeMy WebLinkAbout2026-00030493 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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OH 00000 I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004251111.
u, 1 U21 3 4 1 u, 2 U2 1 u, 1 u2 1 u, 1 U2 1 1 10 u, 5 u2 3 *P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00030493 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mS MCLEAN BLVD Elgin09:44
® ❑ RELATED ' ' 0 N 05 28 2026 ®AM ❑YES ®NO U1
_ _ PRIVATE mo !day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W LILLIANST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) Mao TOWED U1 0
Rumachik.Aldan. M. 0 3 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 M
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N [DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r COM VEH ❑ Ej 1 0
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s l 6 ii,4
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 7 tz_; __5 *II Yes.See Sidebar U1 0
Z K696294 IL REAR ' E
TELEPHONE
IL D JA4AR3AW2GZ044208 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Rumachik. Kelly. E. 0157005-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O NMV 0 NOV 0 DV
!2 0 0 1 Chevrolet Spark 2014 00-NONE i1_"j Qr,-_, DUE TO CRASH ❑ El 2 73
oy Yr 13-UNDER CARRIAGE 10( ) 2 FIRE ❑ ® U2 C
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH D ® U1 CO
FIRST CONTACT 12 7 _.5 •It Yes.See Sidebar
i ELGIN IL 60120 0 1 0 CM39325 IL 2025 I 0
IL D KL8CF6S92EC411196 American Alliance ❑Y J N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Najera.Jessica ILAA-1031161-01 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 05 / M 2 4 0 1 0
m
/ / #OCCS D
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 5/ ,81 l026 09 44 ®❑pM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 8 0
T
0
2 ❑ 07 2 r r ❑PM ❑Construction
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Rumachik.Aldan. M. 11-901-A 345000298 / ! ❑PM SLMT
S' N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
I 2 ARREST NAME AM
T r r ❑❑pM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ElAM Workers present? ❑Y 30
345-Gomoll.Geoffrey 601 331-Ziegler r 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
r I ICO combination): r more than pound (example:truck or truck/trailer 1. Has a weight rating10 000 5 i -<
INDICATE NORTH tan)o p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I - } (example:shuttle or charter bus):or
1 X
rl< Initid7Point7aRCan- 3. Is designed to carry15 or fewer
J
I I ' r 5 passengers and operated by a contract carrier I O
- } } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
---_a -4 uianzsveer 4. Is used or designated to transport between 9 and 15 passengers,including the driver, '
<z` ! / �- } } 1. •
for direct compensation(exam :large van used for specific purpose):or O
it
L .l. -
i. 1 i L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
r placarding(example:placards will be displayed on the vehicle). m
0
CARRIER NAME Z
« I 4.I I 1 ADDRESS 0
T.
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scale I I I - O
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - '-1 - 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
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
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE