HomeMy WebLinkAbout2026-00016006 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110
ll 11110111ll 11U0 10 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 04176764
u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U223 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2026I 2026-00016006 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 I
610 WATERFORD RD Elgin05:08
® ❑ RELATED ❑Y ®N 03 23 2026 12,— ❑YES ®NO U1 -<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ 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 ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
FRONT TOWED U1 O
NAME(LAST,FIRST,M) mo yr
Sternak. Kamil Unknown Unknown 2001 00-NONE „ 12 , DUE TOCRASH 0EN
13-UNDER CARRIAGE 101 ! 2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL)THERDISTRACTED ❑ 0 U2 1 m
M 18 3 SYTM❑Y INS NEDUNK VEH. O ATCRASH 0 15-99-UUNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ij B 4 COM VEH 0 0 1
H F. Elgin IL 60124 A 9 9 NONE FIRST CONTACT 12 r ; _s *IrYes.See Sidebar U, 0
Isui
Z E
TELEPHONE
UNK. Other 0 None Provided ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Elgin Fire 1 61 1 Sternal:.Grazyna None Provided 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑Nuy 0 i v ❑DV
!1 9$6 Subaru Outback 2015 Do-NONE 1("j 12 NT..-_, DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10'i 2 FIRE ❑ ElU2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 al lC COM VEH ❑ ® ut W
FIRST CONTACT 7 O7 ,�== �._5 •)ryes.See Sidebar
ELGIN IL 60124 0 1 0 DX24447 IL 2026 FIRST Z
IL D 0 4S4BSELC2F3210527 Country Financial ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Poett.Jason.A. PO10258274 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
iUNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONEI (EMS) (HOSPITAL)
2 4 05 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 03,23 ,2026 05 13 ®AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 28 10 03,23l2026 05 13 pM
® • ❑Construction >F
Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
— N a ARREST NAME 03!23,2026 05 17 ®pM
, '
SECTION CITATION NO. ROAD CLEARANCE TIME
1 ® El Utility 11 1 0 CITATIONS ISSUED ❑PENDING SLMT
S' 0 AM
r 2 ❑ ARREST NAME 03 r 23 /2026 05 34 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? 0 Y 30
1542 Chafe. Ethan 801 269-Mendiola , ❑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:
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
-<
i- }---.r----; - ( NORTH combination):or -I
Nof To Scale INDICATEC
1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ i., J ±,, #. _ (example:shuttle or charter bus):or 0
4 • • r 3. Is designed to carry15 or fewer,p,5• + ig passengers and operated a contract carrier O
I- <.__-A-.-.J �`) .♦.. } } } } transporting employees in the course of their employment(example:employee X
or c0
C
L L.___a.._.� 4.Is uosed or dr- es gnated to translly a van type port betweeicle or n 9 and 15r rpr ssen rs,including the driver,...
. } for direct compensation(examp large van used for specific purpose):orNL L____a..... � ,,� •
i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I 7 I ..� j,,1t2 c` _ placartling(example:placards will be displayed on the vehicle).
•
A
��` CARRIER NAME Z
fir• - ADDRESS O
. .:, V)
- 40° CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
, _Y_ _.., USDOT NO. ILCC NO. m
XI
Source of above z
.
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'; 0 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
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE