HomeMy WebLinkAbout2026-00059446 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00059446 VENT
ADDRESS NO. HIGHWAY or STREET NAME INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m®CITY TOWNSHIP ❑ RELATED ❑Y ®N 09 30 2026 ®AM ❑YES ®NO U1 —<
617 S RANDALL RD Elgin 10:02
g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Zarco. Petra 0 2
yr 13-UNDER CARRIAGE 10 2 1 12 �. FIRE 0 NI <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOM
�3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;ii 6 ii,4 COM VEH 0 181 1 O
ZELGIN IL 60123 0 1 0 4157269B IL FIRST CONTACT 3 r __s •II Yes.See Sidebar Ut
TELEPHONE
IL 1 C6SRFLP7SN744542 Allstate ❑v ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Zarco.Antonio 962921951 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0
yr Hyundai Elantra 2023 00-NONE 0Qj.O DUE TO CRASH ❑ (� 2
.ia0 13-UNDER CARRIAGE 10 I D 2 FIRE El ® U2 C
c
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrag 0 lon Value U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .ii�.._ 4 COM VEH D ® CO
FIRST CONTACT 11 7 _, _s •If Yes.See Sidebar C
H Carol Stream IL 60188 0 1 0 L383836 IL I:EaR 0 N
Z
IL D KM H LS4AGOPU447565 Farmer's Insurance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 543370295 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 09,30 /2026 10 02 ®❑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 C)
di, 2 ❑ 04 99
N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) 0 PM, El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / El PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
00
t 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
0 Y 00
345-Gomoll.Geoffrey 702 320-Cox / ( ❑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
i- i•____r____; ; 0 - 1 combination):or more than pound (example:truck ortruckrtrarler 1. Has a weight rating10 000 si '�
INDICATE NORTH -4
Unit BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or 0
X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
L L____A____I 7
- l• l- . transporting employees In the course of their employment(example:employee X
•
transporter-usually a van type vehicle or passenger car):or CO
< <-___A--_-; ; ilnrtlenPdnr?or7canmcc, J C
o _ I* 1 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver w
yfor direct compensation(example:large van used for specific purpose):or O
L L____a____. I
0 _ L l < I. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). 73
•
CARRIER NAME Z
, 0
ADDRESS
cn
0
CITY/STATE/ZIP E
MOTOR CARR.ID 0 Interstate 0 Intrastate --
Not lb Scale ` o
-
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
;____Y____ - USDOT NO. ILCC NO. m
m
• I Source of above Z
. . -a
Were HAZMAT placards on vehicle? 0 Yes 0 No —t
If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xt
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown E
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash? p
❑ Yes lI No E] Unknown C
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7(1
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
_ m
x
IDOT PERMIT NO. WIDELOAD-; 0 Yes 0 No =
' TRAILER VIN 1 _ m
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft N
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT" 1 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