HomeMy WebLinkAbout2026-00007189 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0011110 lifi
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00007189 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
NESLER RD Elgin03:13
® ❑ RELATED ®Y ❑N 02 06 2026 ❑AM ❑YES IX]NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION MFT!MI N E S W DAISY LN COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ 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 0 PEDAL 0 EWES ❑NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
1 1 /
yr 13-UNDER CARRIAGE } O FIRE ❑ tg)
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 0 171
M 2 8 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN THER9 •76•TOP 3 `Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i1 6 I,.4 COM VEH 0 0 1 0
~ ELGIN I L 60124 0 1 0 FIRST CONTACT 12 7 ;{ _5 *II Yes.See Sidebar Ut
Z CZ44423 IL 2026 REAR
M TELEPHONE
IL D 0 3N1AB7AP2FY254703 State Farm ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire MIKOWSKI, ELIZABETH. L. 3897983-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 KV 0 Dv
yr 12
0 13-UNDER CARRIAGE 10 1 Ir y FIRE 0 ® U2 C
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F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN Oistracuon Value 9 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 ( 4 COM VEH El ® U1 toFIRST CONTACT 1 7 . -5 *If Yes,See Sidebar
ELGIN IL 60124 B 1 0 ES93504 IL 2026 I 4 Si)C
IL D 0 WA1 FAAFY9R2112768 Allstate ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Elgin Fire RIKHSIBOEV,JAMOLIDDIN,J. 974941087 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)/ITELEPHONEI (EMS) (HOSPITAL)
1 3 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 02,06 ,2026 03 13 ®AM in a Work Zone? ®N DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 2 28 02/06 /2026 03 21 ®PM ❑Constrtiction >F
R O 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Mikowski.Xavier,J. 11-901.01 1525000929 02,06/2026 03 28 ®PM SLMT
I$!CITATIONS ISSUED 0 PENDING •
SECTION CITATION NO. ROAD CLEARANCE TIME . 0 utility
AM
o t 2 0 ARREST NAME Mikowski.Xavier.J. 11-601-Ax 1525000930 02/06 /2026 04 19 ®PM 0 Unknown work zone type U1 45
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1525-NavE.Oscar 801 320-Cox 03 ,24/2026 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.
till 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 truckrtrailer -<
i- }-- --I-- --' Not To Scale !'` / - INDICATE NORTH combination):or -I
BY ARROW 2 Is used ordesi nedtotran transport C g sp passengers including the driver
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(example:shuttle or charter bus):or 0
L A } 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } transporting employees in the course of their employment(example:employee X
f transporter-usually a van type vehicle or passenger car):or co
C
L }-----}----; / - } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
for direct compensation(example:large van used for specific purpose):or
L L____a____. Dals / t i. i. L 5 Is any vehicle used to transport anhazardousmateral(HAZMAT)thatrequires
71
Unit placarding(example:placards will be displayed on the vehicle). XI
_ n�rrill L i. i. ..... ..... —
CARRIER NAME Z
( __�, - ADDRESS D
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CITY/STATE/ZIP n
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MOTOR CARR.ID ElInterstate ElIntrastate
I I T I / ❑ Not in Comm./Govt. Not in Comm./Other
--'-------1 - USDOT NO. ILCC NO. rn
XI
Source of above 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 ElYes 0 No ❑Unknown Out of Service ❑Yes ❑No _<
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Blue
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