HomeMy WebLinkAbout2026-00034514 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 0427 992
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2026I 2026-00034514 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n
® ❑ RELATED ®Y 0 N 06 15 2026 ❑AM ❑YES ®NO U1 -<
N LIBERTY ST Elgin05:47
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W COLU M BIA AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 !
yr 13-UNDER CARRIAGE 16 IE
1 !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M I 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TIDP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ij 6 �i 4 COM VEH 0 0 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 7 . -_5 *II Yes.See&debar U1
Z 1 KUJAK-B I L 2026
TELEPHONE
IL D 0 1 FTNS24L09DA15877 State Farm ❑Y Igl N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2576946 SFP 13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y Ell 2 c
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 NMv 0 NOV ❑DV
!1 9 y6r 6 Chevrolet Impala 2019 00-NONE ,1_' 12.._, DUE TO CRASH ❑ C 2
o 13-UNDER CARRIAGE 10,1 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16•TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0�`i 6 I1,_4 COM VEH ❑ ® U1 CO
C
FIRST CONTACT 8 l:l;� 1>__5 •(ryes,See Sidebar
Z SOUTH ELG I N I L 60177 0 1 0 H572428 I L 2027 0 Si)
M
IL D 0 2G11Z5S38K9105420 Farmers New Century Ins ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 542697384 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER ui =
(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 ❑Y U2 Z
N 1 ® 11 1 61 ,51 ,026 05 47 ®pm in a Work Zone? ®N DIRP co
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
0 2 28 03 / / ❑PM ❑Construction *
Z 3 ❑ I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a ARREST NAME Kujak. David. E. 11-601 S1519-000543 ( ! El PM 1 El1 1 1 ❑CITATIONS ISSUED PENDING UtilitySLMT
,
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
Ti 2 ❑ ARREST NAME 6) (5) 1026 04 15 ®PM 0 Unknown work zone type U1 0 AM
3O
D'
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1519-Bae2 a.Guadalupe 201 ( ! ❑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---- N7LIBERTY?ST . A - INDICATE NORTH combination):or -I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
f ® _ } (example:shuttle or charter bus):or
X
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I- }____A_.__� Not 7b Scale - y } } } transportingemployees in the course of their employment
typepassen car):(orxample:employee w
transporter-usuallya van vehicle or
L -----------+ •- • } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, y
1 t for direct compensation(example:large van used for specific purpose):or
L i.____a____.I o I t i ii. , 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
-u
, placarding(example:placards will be displayed on the vehicle). ,Zmt
—I
I
. CARRIER NAME
J COLUMBIA?STi. i. ADDRESS 0
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- — — — i. i. i. 4. C
CITY/STATE/ZIP g
1 I r - MOTOR CARR.ID 0 Interstate 0 Intrastate 5
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 - USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
to
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 Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE