HomeMy WebLinkAbout2026-00002737 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
00111101 00
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X101156
u, 1 U21 3 4 1 U1 4 U2 1 U, 1 u2 1 u1 1 u2 1 1 11 U1 1 U211 *P 0119*
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$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202612026-00002737 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mN RANDALL RD Elgin03:41
® ❑ RELATED ®Y ❑N 01 14 2026 12,— ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
0 !MI N E S W Brinckman WayCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) mo
!1 9 7 9 Chevrolet Silverado 201 9 00-NONE 11 1 DUE TO CRASH ❑ EN
Q -
13-UNDER CARRIAGE 10 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 04 r<n
M 2 SY 15-OTHER
4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il S 4 COM VEH 0 j$J 1 0
~ Dekalb IL 60115 0 1 0 FIRST CONTACT 12 7_; _5 *IIYes.SeeSidebar U1
Z 4029955B IL 2026 Ismi
TELEPHONE
IL D 0 3GCUYDED2KG211258 Allstate ❑v ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same 811923741 4 m
17
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y ® N 2 0
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
/1 9 6 2 Hyundai Tucson 2022 00-NONE 11 12'-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 1 1 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellen VaIee 9 0
POINT OF s iI 4 COM VEH ❑ ® Ut W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 6 1'
FIRST CONTACT 6 Y__{_O ._5 If Yes.ELGIN IL 60124 0 1 0 DC73816 IL 2025aR
D
IL D 0 5N MJ ECAEON H054634 Geico ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 4564-15-36-84 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 ❑Y U2 Z
N 1 ® 11 1 11 ,41 l026 03 41 ®AM 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)
0 2 ❑ 28 03 { / ❑PM ❑Construction *
1
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
aD ® 11 1 ARREST NAME Zavala Zavala.Jose. L. 11-601-Ax 1561-000202 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM
r 2 El ARREST NAME 11 141 1026 03 41 ®PM El Unknown work zone type U1 5O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 50
1561-Sarovic• Mirko 901 337-Thompson 21 , 12 ,26 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Black
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE