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HomeMy WebLinkAbout2026-00027718 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I0110 11111 )III IIIII IIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X{30t4234.512 u, 9 U21 1 1 1 u, 8 U2 1 U1 99 1_12 1 u,99 U2 1 5 12 u, 18 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ❑ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00027718 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m RT20 EB Elgin 10:10 ® ❑ RELATED ' V 0 N 05 15 2026 ❑AM ❑YES El NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W GRACE ENT RAMP COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ 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 0 PED ❑PEDAL 0 EWES ❑NOV ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q Unknown.O. ! ! T Unknown Unknown 00-NONE ©, 12 , DUE TOCRASH ❑ Ezi NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE 10.I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 M SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,Ii_S Ii,_ 1 I— 0 9 FIRST CONTACT 11 7_: COM VEH 0 Ea_5 *II Yes.See&debar U1 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 N/A ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same N/A 1 I- `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ❑ N 99 G0) g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ !2 0 0 9 Hyundai Tucson 2025' 00-NONE ,, ' t2 DUE TO CRASH 0 2 x o 13-UNDER CARRIAGE I FIRE ❑ ® U2 c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9I1,6.TOP 3 X ❑Y lYi N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraction Value 9 0 POINT OF 8 i1 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR s �f_ FIRST CONTACT 1 Y , _5 C. If Yes.See Sidebar Z Wood Dale IL 60191 0 1 EX88491 IL 2027 REAR 0 N IL D SNMJBCDE6SH444413 State Farm ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = KOWALIK. Nobert 3730251-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)(TELEPHONE) (EMS) (HOSPITAL) 2 3 03 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 9 05/15 l2026 10 34 ®pm in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n T v , 2 0 2 06 1 / ❑PNI ❑Construction X Z 3 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a, ARREST NAME / / 0 PM ' o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 50 t 2 ARREST NAME AM T / / ❑❑PM 0 Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 1534-Santiago.Jorge 401 341-Cox / / ❑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 -< i- }____r____1 INDICATE NORTH combination):or 531(-.".! BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ ,o _ r (example:shuttle or charter bus):or 0 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O } A i } } } transporting employee In the course of their employment(example:employee X C L }-----}----; u„ni, - } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and r 1 passengers,including the dryer, for direct compensation(example:large van used fors specific purpose):or L L----a--- UnI1112 ——— L i i iany 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI - CARRIER NAME Z ADDRESS 'T. C) CITY/STATE/ZIP MOTOR CARR.ID ❑ Interstate ❑ 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 . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI 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 VIM 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 Black Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE