HomeMy WebLinkAbout2026-00032110 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets II 111 I M IIIIII U
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004276522-
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El 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 N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash
0 AMENDED YR 2026I 2026-0003211 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :l
® ❑ RELATED ❑Y ®N 06 04 2026 ❑AM ❑YES N NO U1
N STATE ST Elgin08:47
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
25 FT/vt N E S W Tollgate Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 Cl)
® ® 0 g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 0Shte k. Roman 0 4 /
yr 13-UNDER CARRIAGE 10:) 2 ' 2 FIRE 0
lE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 SYTHER
4 ❑Y ONM❑UNK VEH. 0 AT CRASH IN ENGAGED 0 99-UNKNOWN 9 76_TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;iI 6 4 COM VEH 0 igJ 1 0
~ Park I L 60068 0 1 0 FIRST CONTACT 12 7 . _5 *Irves.See Sidebar U1
ZRidge10852WS I L 2026
TELEPHONE
IL C 0 WAU3MAFD9FN000637 American Alliance ❑Y ISI N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same I LAA-0859199-05 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑NMv 0 NCV ❑DV CIRCLE NUMBER(S) U1
!1 9 9 1 Nissan Rogue 2017 00-NONE ,�_"i t2'-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ N U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y Ig N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistract Dn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
iII 6 �, 4 COM VEH ❑ N ut CO
FIRST CONTACT 6 Y__{_O ._5 •IfYes.See Sidebar REAR C
Z Carpentersville IL 60110 0 1 0 EZ16118 IL 2026 0 Si)
D
IL Other 0 5N1AT2MV4HC838888 Safeway ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 4233525-I L-PP-003 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 06,04 l2026 08 47 ®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 ❑ 28 03 { ) ❑PM ❑Construction *
R 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o D ® 11 1 ARREST NAME Shteyuck. Roman 11-601-Ax 1563-214 ! ! El PM SLMT
ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N 0 AM45
t 2 El ARREST NAME Jimenez-Toledo.Judith 6-101 1563-215 1 ! PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
1563-Rodriguez.Carlos 501 337-Thompson 07 ,21 ,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
I I I I ADDITIONAL UNITS FORMS.
r ----r••--, , I I I I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I I I I 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }----Y----; ill I Nat Tea sub f r INDICATE
ARROW NORTH
combination):or -I
BY2 Is used or designed to transport more than 15 passengers including the driver C
IIII _ (example:shuttle or charter bus):or 0
.,
L A Tollgate?Rd 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees in the course of their employment(example:employee °
transporter-usually a van type vehicle or passenger car):or w
i. .:. __I.,.. ...I " - I. } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
I I I f for direct compensation(example:large van used for specific purpose):or O
L I I I t i. } i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
I4. 1 placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME Z
I I J.
i _ ADDRESS D
+I� rn
a I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 IL CC NO. CC NO.
m
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 VIN 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
White White
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 DUETO TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® Arties VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE