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HomeMy WebLinkAbout2026-00033071 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 11111100IV 1111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 04265250 u, 1 U21 1 1 1 U1 5 U2 1 u, 1 1_12 1 U1 1 U2 1 1 10 u, 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 15 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202612026-00033071 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ADAMS ST El In 03:41 ® ❑ RELATED ®Y 0 N 06 09 2026 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W S STATE ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR NI SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 4 / Honda Accord 2000 00-NONE 1.,..' ©' O DUE TO CRASH ® ❑ ' E 13-UNDER CARRIAGE 10, 2O FIRE ❑ ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 m F 2 5 SYTM❑Y OS NE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP® *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL a ii,4 COM VEH ❑ j$J 1 0 I . Hanoverpark IL 60133 0 1 0 FIRST CONTACT 2 7_; _-5 *5Yes.SeeSidebar U1 Z G B85010 I L 2026 REAR TELEPHONE IL D 0 1 HGCG5678YA057371 Progressive ❑v Il N U2 St , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 999839888 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER eM Refused ❑Y El 2 0 Eg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 i uv 0 CIRCLE NUMBER(S) U1 CV ❑Dv /2 0 0 7 Honda Civic 2015 00-NONE O Qi-O DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 7� , .5 ••(ryes.See Sidebar H ELGIN IL 60123 0 1 0 FE84629 IL 2026REAR- C M IL D 0 19XFB2F84FE093344 American Alliance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Gomez Gomez. Mercily.m. ILAA-1012393-01 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL) 2 3 10 / M 2 5 B 1 0 m / / #OCCS > / / U1 1 D / / 2 O EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z N 1 ® 11 4 61 ,12 /26 03 41 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) en 2 ❑ 28 15 61 /12 /26 03 46 ®PM ❑Construction * " 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 z J ❑AM ❑Maintenance U2 a1 ® 11 4 ARREST NAME Tannehill. Michael. D. 11-1201-A- 1556-196 61 /12 /26 03 41 ®pM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility AM t 2 El ARREST NAME 61 /12 /26 04 11 ®PM ❑Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1556-Sanchez.Jimena 701 378-Alcorn 71 , 12 /26 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 I ADDITIONAL UNITS FORMS. 0 r ----r•- --, A CMV is defined as any motor vehicle used to transport passengers or property and: z):'___ ___ _ Not To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< r r -'- -' • INDICATE NORTH combination):or .Z—I1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C r r r (example:shuttle or charter bus):or 0 '-e•" 3. Is to designed carry 15 or fewer passengers and operated a contract carrier 0 I. } } transporting employees in the course of their employment� (example:employee � 73 1, )i transporter-usually a van type vehicle or passenger car):or •L L.___a-_._� w' ,', - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y 1 7 1 4�r1 for direct compensation(example:large van used for specific purpose):or O L L L I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m Adams43rlirl s � ' placarding(example:placards will be displayed on the vehicle). - -- —1 CARRIER NAME Z - __ ADDRESS 'O szsmayst T. C) CITY/STATEJZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 1 1-: , , ... , 1 I r ❑ Not in Comm./Govt. Not inComm./Other r r • r USDOT NO. ILCC NO. m XI Source of above z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Green White u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE