HomeMy WebLinkAbout2026-00047868 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00433329
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00047868 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
DUNDEE AVE Elgin03:47
® ❑ RELATED ®Y 0 N 08 09 2026 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROM T TOWED U1 Q
Zamzam. Mohammad 1 1 /
yr 13-UNDER CARRIAGE ) I! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) NI
�� O DISTRACTED 0 ]$I U2 0 m
M 2 4 ❑Y OSYNM DUNK VEH. O AT CRASH 0 99-UUTHER NKNOWN 9 16•TOP43 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ij S it®COM VEH 0 ix) 1 C)
H Z CRYSTAL LAKE I L 60014 0 1 0 FIRST CONTACT 3 r: -� 'If Yes.See Sidebar u1
CC56323 IL 2027 E
TELEPHONE
IL D 0 3N 1 CN7APXH L890401 Geico ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Same 6094-85-04-24 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 18 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 i v 0 DV
!2 0 0 2 Nissan Murano 2011 00-NONE 0. Q!'-O DUE TO CRASH ❑ 2 x
o y Yr 13-UNDER CARRIAGE 19( 12 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COMVEH ❑ ® U1 CO
FIRST CONTACT 12 T _,•_5 •If Yes.See SidebarC
F-
. . ELGIN IL 60120 0 1 0 FQ63129 IL 2027 I 0
IL D 0 J N8AZ1 MW3BW156584 MAGNUM ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
99 9 Same ILU012227 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB( (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 08 /
/ / UI 2 :A
m
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 08/09 l2026 03 47 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 2 18 08,09 ,2026 03 59 RI ❑Construction >F
R 1 3 ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
z J ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Zamzam. Mohammad 11-901-A 1570-000250 08,09/2026 04 13 Igi pM CITATIONS ISSUED 0 PENDING SLMT
l •jgUtility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• y
t 2 El ARREST NAME Cobon Gomez. Magdali. M. 11-601 1570-000251 081 09 /2026 03 47 ®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
1570-Tomlin. Eli too 09 ,08,2026 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••--, , Not To Scale I A A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
i- }____r__--; / / } INDICATE NORTH combination):or —I
_ p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
/ / _ (example:shuttle or charter bus):or C
/ / r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}. -A- --i - / }} } transporting employee �In the course of their employment(example:employee
y a van type
L L.___a__..� - li "o 4alsuosedordrter- estlnatedto transport betweeicle or n9 and r15r) ssen rs,induding[hedriver, to
/ } } 1. for direct compensation(examp large van used for specific purpose):or O
•
L i.--_-a-....I n;� - - t i. 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m
- - — — '' I I I I P n9( P P PY )Wcardi exam le: lacards will be dis la ed on the vehicle :021.
II _ CARRIER NAME Z
°10°AMorl 4 l ADDRESS '0} 1cill
D
1 1 rn
1 O
t CITY/STATE/ZIP g
` - i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 , ❑ Not in Comm./Govt. 0 Not in Comm./Other
USDOT NO. ILCC NO. m
XI
Source of above z
. 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 ❑ 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
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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