HomeMy WebLinkAbout2026-00001665 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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III II 11 IIIIIIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0041 12224
u, 9 U2 1 1 9 U1 99 U2 U199 1_12 U199 U2 1 4 9 U1 1 U221 *P 0119*
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 ❑$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512026-00001665 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
145 S RANDALL RD El In 08:00
® ❑ RELATED ❑Y ®N 12 22 2025 DAM ❑YES El NO U1
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR IR SLOW 2 fA
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
&RUN
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGED AREA(S) FRO4T TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 1 IE
01 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 00
~ 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
UNK ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same UNK 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r My 0 NOV 0 DV
yr 13-UNDER CARRIAGE 11 112 1 FIRE 0 El U2 C
Ti2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16•TOP 3 0 ® SPDR 0
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 9 -
POINT OF 8 I I
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 10 7'._:.� B lL`=5 C•IO f VEH
Sidebar❑ ® C
CO
H 3535594E IL 2026 I0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 GCVKREC1 FZ310296 Progressive ❑V ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Bajorek. Eric 986131245 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP
U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 01 ,09 l2026 03 10 ®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
2 0 18 18
N 3 0 ❑CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ❑PM '
S' N ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
00
t 2 0 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 00
1515 BellEck.Stacy 702 , / 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----; - combination):or —I
INDICATE NORTH A
CK BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
C.- _ (example:shuttle or charter bus):or
i CO 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I- ------I-----� : } } . transportingemployees In the course of their employment(example:employee
p
� N transporter-usually a van type vehicle or passenger car):or co
i. �. i CC - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
00. for direct compensation(example:large van used for specific purpose):or O
L L---_a...-J. - t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1.0 placarding(example:placards will be displayed on the vehicle). ;p
-I—I
CARRIER NAME Z
ADDRESS 0
0
CITY/STATE/ZIP g
.
L4.7 - MOTOR CARR.ID 0 Interstate ElIntrastate 5
I ❑ Not in Comm./Govt. 0 Not in Comm./Other
0
' Nut To Scafu : i. '
USDOT NO. ILCC NO. m
73
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. 71
73
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 g
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
cn
LOCAL USE ONLY TRAILER VIN 2 m
O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE