HomeMy WebLinkAbout2026-00055988 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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0111011111 III III I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XG0438438
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00055988 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
SHALES PKWY Elgin 04:54
® ❑ RELATED ®Y 0 N 09 14 2026 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W E GH ICAGO ST COUNTY PROPERTY ❑Y 2�I N DOORING ❑y #OF MOTOR 0 SLOW 1 0)0 Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) GHOSH.SARM I LA mo /
13-UNDER CARRIAGE } �:/ FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 'O DISTRACTED 0 !$l U2 2 I'T1
F 2 4 SYTM❑Y MS NE❑UNK VEH. 0 AT CRASH 0 99-U 15-UNKNOWN THER 9 S TopQ `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL a 4 COM VEH 0 )$J 1 0
H 1- ELK GROVE VILLAGE I L 60007 0 1 0 FIRST CONTACT 12 T ; _s ves.See Sidebar Ut
Z BM43514 IL 2026 ' E
TELEPHONE
IL D 0 4T1 BD1 FK1 HU203944 ALLSTATE ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 811382493 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused 0 Y ❑ N 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑
yr Q t2;.Q C
0 13-UNDER CARRIAGE f.` FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 90TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraeion Value 9 9
POINT OF s 4 COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Y_;I-6 ,._6 C• MYe See Sidebar
zSCHAUMBURG IL 60193 0 1 0 DZ30926 IL 2026 9 N
M
IL D 0 1 N4AL3APOHC138209 NATIONAL GENERAL ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 42781 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
St.Alexius Medical Center 0 Y°ND
O N u1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJ) 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
3 6 09 /
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EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 09,14 /2026 04 54 ®FM in a Work Zone? ®N DIRP co
1 t 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 15 28 / / ❑PM ❑Construction *
N 3 ❑ igl CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a GHOSH.SARMILA 11-601-Ax 1516-000569 / / PM
-, ARREST NAME ❑
I$!CITATIONS ISSUED 0 PENDING - TIME ' 0 Utility SLMT
o N ® 11 1 SECTION CITATION NO. ROAD CLEARANCE 0 AM u1 35
t 2 El ARREST NAME GONZALEZ ARAGON. LESSLY. L. 4 S1516-000570 , / pM 0 Unknown work zone type
2 2 3 El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1516-Mancera. Maria 302 393-Gutierrez 10 /20,2026 09 00 0 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 INDICATE NORTH comb natbn)or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
- } (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or co
L }-----}----; J ` - I. } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
Ir for direct compensation(example:large van used for specific purpose):or O
L L__ _a____� M - _ l. i i t 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires
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placarding(example:placards will be displayed on the vehicle).
Mill-
0 a CARRIER NAME Z
ADDRESS 0Not To Scale f I uDi
CITY/STATE/ZIP n
g
- 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. rn
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No 2
TRAILER VIN 1 m
W
LOCAL USE ONLY TRAILER VIN 2 fTl
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red 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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE