HomeMy WebLinkAbout2026-00027430 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 4235336
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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 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00027430 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
COLLEGE GREEN DR Elgin04:38
® ❑ RELATED ®Y ❑N 05 14 2026 12,— ❑YES El NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT N E S W S MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑Y #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®N ® FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
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NAME(LAST,FIRST,M) Juza.Carol. E. mo
13-UNDER CARRIAGE I O FIRE ❑ tg)
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)15-OTHERDISTRACTED ® 0 U2 0 m
F 2 8 ❑Y ❑SNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ;iI 6 4 COM VEH 0 Ea 1 C)
FIRST CONTACT 12 7__� ,__5 *IIYes.See Sidebar U1 0
Z ELGIN IL 60123 B 1 0 CUB1 US IL 2026 REAR
M TELEPHONE
IL D 0 2G1115S39G9165821 Trumbull Insurance Compan ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 55PHL158885 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman 0 Y El 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NuV 0 i v 0 DV
!1 9 8 9 Acura MDX 2017 00-NONE 11 _.Ai,O DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE I, FIRE 0 El U2
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F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOPO3
❑Y NJ N ElUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 4
POINT OF 8 .i.�.I"_4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 11 7A -5 •If Yes.See Sidebar C
ELGIN IL 60124 B 1 0 FX25288 IL 2026 I 4 Cl)
IL D 0 SFRYD4H56HB040304 Travelers ❑Y J N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire Nadeem.Yasir 6178693042031 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 05 / M 2 8 B 1 0
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 05,14 /2026 04 38 ®AM in a Work Zone? ®N DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 25 28 05,14 ,2026 04 38 El PM El Construction
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R 3 ❑ zi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Juza.Carol. E. 11-306 1525001014 05,14,2026 04 45 Igi pM SLMT
l$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME NAM' 0 Utility
t 2 El ARREST NAME Juza.Carol. E. 11-601-Ax 1525001015 05)14 ,2026 05 05 ®PM 0 Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1525-NavE.Oscar 702 337-Thompson 06 ,23,2026 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
0 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 truckrtrailer -<
i- }----------I I Not To Scale 1 - INDICATE NORTH combination):or .Z-1
1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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(example:shuttle or charter bus):or 0
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I- I- A I 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
transporter-usually a van type vehicle or passenger car):or w
L L.___a.._..l 4. Is used ordesinatedtotrans rtbetween9and15passengers,includingthedriver. C
I I I J Unitlt } } } for direct compensation(examp large van used for speific purose):or 0
L L..._J_ - l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). m
__ D
'— j'=— CARRIER NAME Z
._ ADDRESS 0
c g zctranirfor I o
CITY/STATE/ nZIP 0
_ i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
-----------; I -
USDOT NO. ILCC NO. C
m
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 ❑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
71
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' M
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Maroon Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE