HomeMy WebLinkAbout2026-00018004 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III 11 IIII
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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 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202612026-00018004 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED ®Y 0 N 04 02 2026 ❑AM ❑YES ®NO U1 -<
DUNDEE AVE Elgin05:19
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W 190 EB EXPY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Shpakivskyi. M khailo 1 1 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 r<rl
M 2 SYTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN ENGAGEDO 99-UNKNOWN 9 16-TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i� 6 �I COM VEH 0 Ea 1 n
.V. Z Chicago IL 60656 0 1 0 EX72349 IL 2026 FIRST CONTACT 5 7 ;REAR
_O =II Yes.See Sidebar U1
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TELEPHONE
IL D 0 5UXKR0057G0U48475 Horace Mann ❑Y Il N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Same 65002813980101 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused El ® N 2 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 Nov 0 Ncv 0 DV
+2 0 0 3 Toyota Camry 2009 00-NONE 11_"i Qr O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 I ), 2 FIRE 0 ® U2 C
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M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraglon Value 0
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 8 7 B 4 COM VEH ❑ ®
_5 •
— Mundelein IL 60060 0 1 0 FR59794 IL 2026 REARIfYes,See Sidebar U1 W
0 N
IL D 0 1 NXBU40E79Z110612 AmericanAlliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same I LAA-1115319-00 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (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 0 Y U2 Z
N 1 El 11 4 04,02 l2026 05 19 ®pm in a Work Zone? NJ o1RP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1
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2 0 2 28 ( ( ❑PM- ❑Construction X
" 1 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o1 ® 11 4 ARREST NAME Shpakivskyi. Mykhailo 11-902 1527000425 / ! ID Pm SLMT
o N
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑0 AM Utility
t 2 0 ARREST NAME 04(02 12026 06 10 0 PM 0 Unknown work zone type U1 35
2 2 3 ❑10
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 35
1527-Juarez.Jorge 102 320-Cox 04 ,28(2026 01 30 ®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 -<
cy t
r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I k? ,. ,. t- (example:shuttle or charter bus):or 0
L i ' 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- t t t t transporting employees In the course of their employment(example:employee X w
transporter-usually a van type vehicle or passenger car):or
- t t 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
�I
Il _ —-_ for direct compensation(example:large van used for specific purpose):or O
,.
.D
__ i i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle).
- I."' >
x..r CARRIER NAME Z
JAIADDRESS 0
2
Iv CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS C
❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No z
Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
White White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
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/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE