HomeMy WebLinkAbout2026-00018326 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III III 11 IIII
11111111 II IlU
I11111111111 DUO
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 1.�1036
u1 1 U29 3 4 1 Ut 8 U2 1 U1 1 U299 U1 1 U2 99 1 5 u, 1 u2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00018326 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 71
® ❑ RELATED ' ' 0 N 04 04 2026 ®AM ❑YES ®NO U1 -<
N STATE ST Elgin08:33
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W TOLLGATE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 99 to
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DM
U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROr'tf TOWED U1 O
NAME(LAST,FIRST,M) Mcqueen.Jesse.J. 0 8 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M 2 4 ❑Y ®SNEM❑ is-OTHER
UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 •Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO STATE YEAR POINT OF s iI S �i 4 COM VEH El 0 1 0
F. FIRST CONTACT 1 7. _. --___5 *IIYes.See Sidebar U1
Z Crossville TN 38572 0 1 0 P1333405 IL 2026 I ;
TELEPHONE
TN A 7 3AKJ H H DR7TSWR3234 The Trailblazer Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Dawson. Nora TB00000126-01 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 0
6U DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV CIRCLE NUMBER(S) U1
!1 9$8 Mazda Mazdaspeed 6 2018 00-NONE 111 12 (,�2 FIRE DUE OCRASH 0 ® U2 99 C
.. 13-UNDER CARRIAGE
c
F 9 9 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF C)'i- 6 I,,._. COM COM VEH ❑ ® U1 CO
C
FIRST CONTACT 8 Q __,�_5 •(ryes,See Sidebar
ELGIN IL 60120 0 9 0 BP36962 IL 2026 FIRST
Si)0
IL D J M 1 G L1 XY1321855 Travelers ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Shopov. Nedyalko 607901963 203 1 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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 ® 2 4 04,04 l2026 08 33 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 .,
6
2 20 99 1 1 ❑PM ❑Construction *
1
Z 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Mcqueen.Jesse.J. 11-708 W1574-000031 / ! El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
40
t 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 40
1574-Rosales.Alexander 501 r , ❑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. Hasa weight ratingmore thanpounds(example:truck or truck trailer -<10,000
` -' -' I r INDICATE NORTH -1
N i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I I _ } (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} } } transporting employee In the course�of their empbyment(example:employee I :
T ?Rd, transporter-usually a van type vehicle or passenger car):or w
`.___a unn#sL 4. Is used ordesi natedtotrans transport passengers,including C} } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
- — —
L____a_ I i _ t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M
.. m
,_ placarding(example:placards will be displayed on the vehicle).
r8 D
{; CARRIER NAME Ego Express INC Z
v ADDRESS 677 N LARCH AVE
D
Not To Scale I I f
w
1 I I CITY/STATE/ZIP Elmhurst/ IL 160126 g
l - 1 MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other
i"---- -"'- - usDOT NO. 2107840 ILCC NO. rTt
XI
Source of above z
. 0 Yes J 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'7 0 Yes ®No 2
TRAILER VIN 1 3H3V532K7TS003033 m
co
'LOCAL USE ONLY TRAILER VIN 2 m
0
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 60f ft. 2 ft. w
White Red
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