HomeMy WebLinkAbout2026-00037582 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II I 111 IIII
111111 U
I� III III 111O HH 111110 DD
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00428 6555
u, 1 U21 3 4 1 u, 8 U2 1 u, 1 u2 1 u, 1 U2 1 1 10 u, 3 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00037582 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 8 �l
E HIGHLAND AVE Elgin 07:31
® ❑ RELATED ®Y 0 N 06 27 2026 ❑AM ❑YES IX]NO U1 —<
_ _ PRIVATE mo !day!yr ®PM FLOW CONDITION MI
FT l MI N E S W DOUGLAS AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
g 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 2 C)
FOR DAMAGEDAREA(S) FROhrr TOWED U1 Q
Iskakov. Mirlanbek 0 3 /
yr 13-UNDER CARRIAGE i FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0U2 tE 2 rn
M 2 4 SYTM❑Y ®SNE El UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 76•TOP 3 ,Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;i� s 4 COM VEH 0 0 2 O
H lai
Philidelphia PA 19152 0 1 0 AH80628 PA FIRST CONTACT 10 7_;REAR
__s Yes.See Sidebar U1
Z E
TELEPHONE
PA A 7 1XKYDP9X9KJ222523 United States Liability I ❑Y ®N U2 ni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a
Aykol Inc. GL1304995 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr �� 12 ( z FIRE ❑ ® U2 C
o 13-UNDER CARRIAGE
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,19-TOPQ X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN s POINT OF O Oistractlon Value
U1 0
it N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �J 5 li CO4 COM VEH ❑ ®
FIRST CONTACT 2 7_ _, _5 •)ryes.See Sidebar
— Winfield IL 60190 0 1 0 9GGR265 CA 2027 REAR 0 Si)
IL D 2FMPK4J90PBA58904 Progressive ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Hertz Vehicles LLC 925593337 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 6 03 / M 2 4 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 06,27 l2026 07 31 ®AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 20 99
N 1 3 0 xi CITATIONS ISSUED El PENDING + ! 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
o1 ® 11 4 ARREST NAME Iskakov. Mirlanbek 11-709-A 1545-698 , / ❑PM SLMT
o Nu ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
r 2 El ARREST NAME 06/28 12026 08 10 ®PM 0 Unknown work zone type 0 AM
U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1545-VanEycke. Brier nil07 ,28,2026 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
e 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 -<
c ` '' -' r INDICATE NORTH combination):or .Z-1
Not TO Scale [ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i l Y l _ (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated I a contract carrier O
}----------J.
- }} } transporting employee � �In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____1 I } } } C
•4. Is used or designated to transport between 9 and 1passengers,includingthedriver,
1 for direct compensation(example:large van used fors cific purose):or to
L L-__-a.___.I 1 L L 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI_ do D
MP �� CARRIER NAME Z
unit ADDRESS D
rA
CITY/STATE/ZIP n
_ MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
�""Y""1 I USDOT NO. ILCC NO. m
Source of above z
'
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Red Black
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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Mies/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE