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HomeMy WebLinkAbout2026-00034098 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 HH 1111 II UHI U I� liii Hill I��11HID DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004276731 u, 1 U21 3 4 1 U1 4 U2 1 u, 1 1_12 1 u1 1 U2 1 4 11 u1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2026I 2026-00034098 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 71 HOPPS RD Elgin00:52 ® ❑ RELATED ®Y 0 N 06 14 2026 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION MFT!MI N E S W RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ 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 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NW 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n �TOWED U1 0NAME(LAST,FIRST,M) mo yr Gambardella. Michael. R. Ford Econoline E150 2011 00-NONE ©, >2 �/DUE TOCRASH ® ❑ 13-UNDER CARRIAGE 10.I 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 r11 M 2 4 SYTM❑Y ®SNEDUNK VEH. O ATCRASHD 0 15-99-UUNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4 COM VEH 0 Ea 1 0 F. Buffalo Grove IL 60089 0 1 0 FIRST CONTACT 12 7_;1 _5 *IrYes.SeeSidebar U1 Z5178MC IL 2025 REAR TELEPHONE IL D 0 1 FTNE1 EW7BDA67135 OLD REPUBLIC INSURANCE CO ❑Y ®N U2 I-IL' - in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m A-TEC AMBULANCE SERV 24147 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 4 XI Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 l uv 0 NOv 0 Dv !1 9 8 7 Ford F150 2008 oo-NONE .1.,-1 12..-_, DUETOCRASH rg ❑ 2 x o _ -y Yr 13-UNDER CARRIAGE 101 2 FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y MN DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g POINT OF s 4 COM VEH ❑ ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 �' FIRST CONTACT 6 Q;� ,--�•(ryes.See Sidebar Z WEST CHICAGO IL 60185 0 1 0 1503952B IL 2025 REAR 0 N M IL D 0 1 FTRX14W68FB44684 Travelers Illinois Insura ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same 6043748812031 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused 0 Y°ND 0 N u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 05 / F 2 5 0 1 0 U2 996 m / / #OCCS > 71 / / U1 1 D / / 2 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 61 r 41 ,026 00 52 ®❑PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 15 03 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING • + ! - ❑PM- ❑Construction >F SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 -a, ARREST NAME / / ❑PM ' o N 1 El 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 50 r 2ARRESTNAMEAM 7 ❑PM ❑Unknown work zone type U1 El / / ❑ n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 50 1516-Mancera. Maria 801 341-Cox 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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` --I -' I. INDICATE NORTH combination):or —I 73 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - } (example:shuttle or charter bus):or L A I I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O - . - . transporting employees in the course of their employment(example:employee 73 I I L -----}----; - I. I I 1 •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and 15 passengers,including the driver, for direct compensation(example:large van used fors specific purose):or enger car):or 03 �re.s 71 __ I ( _ < . _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires da placarding(example:placards will be displayed on the vehicle). XI Misrr. _ : :. ,__ ...:. CARRIER NAME Z Not To Scale I fillita - __ ADDRESS w n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rn XI Source of above z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes ❑ No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown A 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y White Red u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE