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HomeMy WebLinkAbout2026-00039078 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 1111111011111Hil 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO04295/44 u, 1 U21 2 4 2 u, 2 U2 1 u, 1 1_12 1 u, 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 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202612026-00039078 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I N CLIFTON AVE Elgin 01:02 ® ❑ RELATED ®Y 0 N 07 03 2026 ❑AM YES ®NO U1 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITT FT!MI N E S W LARKIN AVE COUNTY PROPERTY ElY ® N DOORING Ely #OF MOTOR El SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 Irizarry.Jessica. R. 0 1 / yr 13-UNDER CARRIAGE ©i !!. 2 FIRE ❑ ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 M F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _ El N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR1 . POINT OF s FIRST CONTACT 11 7_, it a �i 4 COIN VEH 0 j$J 1 0 0 Hampshire IL 60140 0 1 0 FQ57777 IL L REAR 2 Z __5 *If Yes.See Sidebar Ut 2 TELEPHONE IL D 2FMDK3GC4DBE15223 Progressive ❑Y ®N U2 M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 874256151 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER eM Refused El El 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ /1 9 8 9 Toyota Corolla 2011 00-NONE O Q�-_, DUE TO CRASH ❑ (g► 25 0 13-UNDER CARRIAGE 10( 1. 2 FIRE 0 ® U2 C Ti M 2 4 ❑Y ❑ ❑ SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X N UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI�1:, 4 COM VEH ❑ ® U1 W FIRST CONTACT 11 7 _5 •If Yes.See Sidebar H ELGIN IL 60123 0 1 0 Q553726 IL I 0 C M IL D 2T1 BU4EE9BC593830 AAA Auto Club ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same AUT701083470 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) 2 6 1 2 / F 2 4 B 1 0 m / / #OCCS > / / U1 1 D / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 07,03 ,2026 01 02 ®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 1 C) T o", 2 ❑ 2 11 , , ❑PM• ElConstruction Z3 ❑ lyg CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 a1 ® 11 4 ARREST NAME Irizarry.Jessica. R. 11-305-A 345000305 / / El PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 30 t 2 ARREST NAME AM T El ❑❑PM El Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 345-Gomoll.Geoffrey 601 331-Ziegler 08 / 11 ,2026 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 truck trailer -< INDICATE NORTH 6YARROW combination):or 2 Is used ordesi nedtotran transport —I g sp passengers including the driver C } (example:shuttle or charter bus):or X 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0 5 es pa g pe <. A_._.-: '., - } } } transporting employees in the course of their employment(example:employee X 4 I I 1 [. transporter-usually a van type vehicle or passenger car):or C L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or , O } } I t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p 3Unh2 ,T - , -- CARRIER NAME Z ADDRESS 0 1 . . . . - 0 CITY/STATE/ZIPg Not To Scale I MOTOR CARR.ID ❑ Interstate ❑ Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --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 I ❑No 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 Black Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . 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