HomeMy WebLinkAbout2026-00052123 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110111 fl U .
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 61a56
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00052123 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE 0 Y ®N 08 28 2026 ®AM ❑YES ®NO U1
S RANDALL RD Elgin mo /day/yr 10:56 ❑PM FLOW CONDITION m
•15(� COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR ❑SLOW 1 fA
® �C.7!MI O E S W Weld Rd WITH VEHICLES INVLD IN STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 7 /
yr
Kia Motors Co tima 2017 00-NONE ®
12 , DUE TOCRASH ❑ EN
13-UNDER CARRIAGE 10 1 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r a ii,CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4 COM VEH 0 Ea 1
H I .
Monroe Center IL 61052 0 1 0 CZ49358 IL FIRST CONTACT 11 7_; __s Yes.See Sidebar U1
0
REAR
Z E
TELEPHONE
IL A 7 5XXGV4L2OHG133033 State Farm ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2466004-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 i uv 0 i v 0 DV
9 9 8 Subaru XV Crosstrek 2.0 2026 00-NONE 'o,� t2 (,-2 FIRE DUE o CRASH ® U2 2 C
o Yr 13-UNDER CARRIAGE
c
F 2 4 ❑Y ❑SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 0 X
❑N UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value
POINT OF 8 i1 i 4 U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR J 5
t
FIRST CONTACT 5 7 —_,SOS •C OM VEH((Yes,See Si ❑ ® CO
debar
ST CHARLESZ IL 60175-5461 0 1 0 FX80752 IL BAR
D
IL D 4S4G U H F60T3735363 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 947528316 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 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 81 r 81 r026 10 56 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 03 28 ) ) ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
— U2
a, ARREST NAME Petry,Adam,C. 11-601 w345000319 r r ❑❑PM ❑Maintenance SL
oN 1 ® 11 1 I]CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility MT
r 2 El45
AM
NAMEAM
7 / 1 ❑❑PM ❑
x- Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 45
345-Gomoll,Geoffrey 702 275-Engelke 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 -<
i- }---.r----; _ combination):or
J I INDICATE NORTH/ \ N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
C
} - } r r ,. (example:shuttle or charter bus):or X
f 1I
Unp4 i 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 10
} } } transporting employees In the course of their employment(example:employee X
- . transporter-usually a van type vehicle or passenger car):or r
i.
' I `- ` . 4. Is used or desi nated to trans rt between 9 and 15 passengers, ng cC/t
}--- ----; - } } } g transport passen rs,includi the driver,
IV for direct compensation(example:large van used for specific purpose):or O
L L____a----. M Lii:" - i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
— placarding(example:placards will be displayed on the vehicle).
xwafena t - , , , , , CARRIER NAME Z
ADDRESS 00' 1 l C
CITY/STATE/ZIP 00
Not To Scale - I _ i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
.
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
to
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 Green
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE