HomeMy WebLinkAbout2026-00049783 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004345773
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INVESTIGATING AGENCY DAMAGE TO ANY ❑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$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202612026-00049783 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1
ROUTE 201 SHALES PKWY Elgin® ❑ RELATED ' V 0 N 08 18 2026 09:30 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION M
010 /MI N E sroute 20/shalespkwyCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 C/)
® ® ® Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 7 n
1 2 /
yr 13-UNDER CARRIAGE 10 I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 U2 7 r❑ n M 2 4 SYSTEM IN ENGAGED 15-OTHER 916.70P3 9 ALGN =
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4 COM VEH 0 j$J 1 0
~ Melrose Park IL 60164 0 1 FIRST CONTACT 12 7 ; _5 *IIYes.SeeS:debar Ut
Z 3956808B IL 2027 Ismi
TELEPHONE
IL D 0 1 FTNE24W19DA48579 State Farm ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3974358-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 c
Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑row 0 KOV ❑DV
'1 9 9 Audi A6 2012 00-NONE 'o,� 12 (,-2 FIRE DUE o CRASH ® U2 2 C
o 13-UNDER CARRIAGE ID
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M 2 4 SYSTEM IN ENGAGED 15-OTHER 911,6•TtOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- 1. 6 1(:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 7�. -5 •IT Yes.See Sidebar
Z Johnsburg IL 60051 0 1 AC49589 IL 2027 REAR0 N
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IL A 7 WAUBGAFCXCN004623 Farmers ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Buczkowski. Maciej 187161060 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS))(TELEPHONE) (EMS) (HOSPITAL)
1 3 12 / M 2 3 0 1 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 08/18 /2026 09 37 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 28 99 / / ❑PM• ❑Construction *
Z 3 0 lyg CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Peralta. Estanislao 11-601 273005427 / / El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
Ej T 2 ❑ ARREST NAME AM
7 / / pM ❑Unknown work zone type 45
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
273-Tucker.Craig 302 331-Ziegler 09 /08/2026 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
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
}a.- - 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
combination):or
r }----r----, - -;'�! ,g INDICATE NORTH -1
• BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
. _ } (example:shuttle or charter bus):or 0
X
I _ , �� 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
L L----A--- ° 'f • y } } } transporting employees in the courses of their employment example:employee X
- • . transporter-usually a van type vehicle or passenger car):or �
L i.-----}----; f,,,; - } } •4. Is used or designated to transport between 9 and 1 passengers,including the dryer,
r * for direct compensation(example:large van used fors specific purpose):or
f
I I I ,
—: _�;,r - } } } t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
A�f r _ 4.. W 9
r° placarding(example:placards will be displayed on the vehicle). m
0
. - D
n ' , Yr~ ^-�-r"> CARRIER NAME Z
c./:` r- d ADDRESS D
's fA a• _ ^ ' 0
;� �'. '' c..- --„" 45 _.r.•• CITY/STATE/ZIP
'F .f �.-- - MOTOR CARR.ID 0 Interstate 0 Intrastate
0
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❑ Not in Comm./Govt. ❑ Not in Comm./Other
-----Y----1 - USDOT NO. ILCC NO. C
XI
Source of above Z
. If Yes,Name on placard 0
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
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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. w
White Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE El NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE