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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 10
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00017557 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1
DOUGLAS AVE El In 12:32
® ❑ RELATED ®Y 0 N 03 31 2026 ❑AM ❑YES ®NO U1 -<
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g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
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❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑UUV ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
Mao TOWED U1 Q
NURMAMATOV. KANATBEK. K. mo Outback 2022 00-NONE 0' 12 , DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 rr1
M 2 4 SYTM IN ENGAGE15-OTHER
❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 016 3 `Distraction Value ALGN 2
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Same Q063028813 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
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❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI 6 i_i, COM VEH ❑ ® U1 CO
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(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 03,31 /2026 12 34 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
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2 20 06 / / 0 PM 0 Construction >F
3
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❑AM 0 Maintenance U2
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1 El 11 1Utility
o NSECTION CITATION NO. ROAD CLEARANCE TIME 0
0 CITATIONS ISSUED PENDING
t 2 El ARREST NAME 03/31 /2026 01 20 0 PM El Unknown work zone type U1 30 0 AM
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1568 Baer.Amkar 100 / / ❑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
�____r____; [ ' CDN
_ 1.c Hasa weightra g ore than pound { a p :truckortruck/trailer -<
tin m 10000 s ex m le''''." [I] I
INDICATE NORTH p1
BY ARROW on):or
2 Is used or designed to transport more than 15 passengers including the driver C
} _ } (example:shuttle or charter bus):or
1 Not To Scale 3. Is d fined t carry 5 fewer passengers and operated a contract carrier O
_- I 1 eS o 1 or
} } } transporting employees In the course of their employment(example:employee73
transporter-usually a van type vehicle or passenger car):or co
L ------}----; uen Y f - I. } 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
__ for direct compensation(example:large van used for specific purpose):or to
L L____a____- (---� r _ t i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
ADDRESS 0
T.
rn
CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Gout. 0 Not in Comm./Other
; _Y_ __1 USDOT NO. ILCC NO. m
XI
Source of above z
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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 ❑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
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 Brown
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Jims/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE