HomeMy WebLinkAbout2026-00058579 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004393076
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00058579 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 8 m
DUNDEE AVE EIin 11:42
® ❑ RELATED ❑Y ®N 09 26 2026 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT l MI N E S W GLENWOOD AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FRO T TOWED U1 O
NAME(LAST,FIRST,M) Golovnov. Pavlo mo Freightliner Cdlpscadia 113 2021 00-NONE 1.,..' Q i 0 DUE TO CRASH ❑
VI
13-UNDER CARRIAGE 16. 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 <<Tl
M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 t6.TOP 3 9 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :i1 6 �i,4 COM VEH 0 j$J 1 0
~ Palatine I L 60074 0 1 FIRST CONTACT 1 7_;- -_5 *II Yes.See Sidebar U1
ZP1147502 IL 2027
TELEPHONE
IL A 7 3AKJHHDROMSMK9693 Great West Casualty Co ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
GPA Logistics LLC MCP99024D 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 eu
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 iiuv 0 NCv 0 DV
/1 9 Yr 8 Ford Focus 2018 oo-NONE 13-UNDER CARRIAGE ,�_` 12 "_, DUE TO CRASH ❑ (� 2
1 2 FIRE ❑ ® U2 C
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 016•TOP 3 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i�!;_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 9 7 _, _5 •It Yes.See Sidebar C
ELGIN IL 60123 C 1 FL38365 IL 2027 I Si)0
IL D 1 FADP3K25JL210273 American Freedom Ins ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 12-2534672-00 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPOND 0 N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 3 09 / M 2 4 0 1 0
m
/ / #OCCS >
71
/ / U1 1 D
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 09/26 /2026 11 42 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 20 99 / 1 ❑PM 0 Construction
5
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Golovnov. Pavlo 11-708 414-1154 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
t 2 ❑ ARREST NAME AM
7 1 / pM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
414-Lara. Saul 102 320-Cox 10 ,20/2026 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.
. 0
r ----r••--, , / A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- �____r____I / / _ combination):orra gmore than pounds(example:truck ortruckrtrarler T.
J 1. Has a tin 10 000i -<
/ INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} 1.Wrorwd 1 / _ } (example:shuttle or charter bus):or 0
/ /� 3. Is designed to carry15 or fewer passengers and operated a contract carrier
/ - } } } transporting employee In the course of their employment� (example:employee � X
y a van type
C
L L____a____� / A 4alsuosedordrter- estlnatedto transport betweeicle or n9 and r15r) ssen rs,induding[hedriver,
/ } } for direct compensation(examp large van used for specific purpose):or 0
L L____a____. / L i _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
•u
placarding(example:placards will be displayed on the vehicle). m
71
toot To Scale J - --
/ CARRIER NAME Z
® .? ADDRESS 'Z
to
O
/ CITY/STATE/ZIP V)
_ MOTOR CARR.ID 0 Interstate El Intrastate 5
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
0
USDOT NO. ILCC NO. C
XI
Source of above z
. • m
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
71
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
Maroon Silver
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