HomeMy WebLinkAbout2026-00033048 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIIl
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash
El AMENDED
YR 202612026-00033048 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
SUMMIT ST El In 12:43
® ❑ RELATED ®Y ❑N 06 09 2026 12,— ❑YES ®NO U1
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT N E S W DUNDEEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 0)0 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
FOR DAMAGEDAREA(S) FRObir TOWED U1 I�
NAME(LAST,FIRST,M) Jendo.Jendo.Z. m0 /
13-UNDER CARRIAGE } FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 99 m
M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-UNKNOWN O9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i1 6 �i,4 COM VEH 0 j$J 1 0
H 1- PINGREE GROVE IL 60140 0 1 0 FIRST CONTACT 11 T ;{ __5 *II Yes.See Sidebar U1
ZAW82629 I L 2026 REAR
TELEPHONE
IL D 0 3VW267AJ6GM370557 GEICO El ®N U2 I--
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Jendo.Zoheir.A. 4471207938 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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Ig DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 Ncv ❑Dv
� 1 9$6 Honda Accord 2005 00-NONE 'o_I 12 j, 2 FIREo CRASH D U2 2 C
o 13-UNDER CARRIAGE
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 911 -TOP
3 X
❑Y ®N ❑ ,6 UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'1 S Y®COM VEH ❑ ® Ut CO
F.
FIRST CONTACT 6 O7 �,�=Q�OS •byes.See SidebarC
ELGIN IL 60120 0 1 0 ES25732 IL 2026 FIRST 0
IL D 0 1 HGCM56465A116900 American Freedom ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 12-2498594-00 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 ® 11 1 06,09 �2026 12 44 0 AM 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 C)
0 2 ❑ 03 28 I ) ❑PM ❑Construction *
N 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Jendo.Jendo.Z. 11-601 1569000096 / ! ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
30
r 2 ARREST NAME AM
7 , , ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1569-Jaimes.Julian 10o 331-Ziegler , , ❑❑pM Workers present? ®N U2 30
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 -<
` ` -'- ' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
< i. ......---; I - • transporting mployeeslin 5 thr e coursr es o heir employment example:employeener 73
I. } }
L -----}----; [! - ,. } transporter sed or des gnated to translly a van type poicle or rt between 9 and 15enger rpassen passengers,including the driver. C
} } for direct compensation(example:large van used for specific purpose):or
a'"'"x'� t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
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CARRIER NAME
1 .�, slop-in Z
' ADDRESS 0
CITY/STATE/ZIP n
I � - MOTOR CARR.ID 0 Interstate 0 Intrastate 0
I r Not To Scale ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
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 ElYes 0 No ❑Unknown Out of Service ❑Yes ❑No _<
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Provided their own . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Provided own VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE