HomeMy WebLinkAbout2026-00051348 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II 1UHI
U
Il IflIHIH flUl h1 [II 11
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO04351539-
u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119*
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 ❑SSW-V.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00051348 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
® ❑ RELATED ®Y 0 N 08 25 2026 ®AM ❑YES ®NO U1
WAVERLY DR Elgin 09:15
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn
❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 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 0
0 2 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY n is-OTHER
$ ❑Y ®SNE M DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a �i COM VEH 0 Ea 1 0
I .
ELGIN N I L 60120 B 1 0 FIRST CONTACT 1 7 . -_5 *IrYes.See Sidebar U1
Z 1978053 IL 2026 Ismi
TELEPHONE
IL 0 1 MEFM50U13G606559 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 0853815SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NEW 0 NCv 0 DV CIRCLE NUMBER(S) U1
1 9$7 Volkswagen Jetta 2019 00-NONE O1' t2 "_, DUE TO CRASH 0 ❑ 2 x
0 13-UNDER CARRIAGE 10 I 2 FIRE 0 El U2 C
c
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
POINT OF 8 i1�I 4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 11 7 _5 •If Yes.See Sidebar
Z Glenview IL 60026 B 1 0 FQ75394 IL 2026 I 0 C
D
IL D 0 3VWE57BU5KM064340 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 ALJOHER. HUSSAIN.A. 947154509 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
/ U2 996 r
m
/ / ##occs y
Pj
/ ,, UI 1 D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 81 /51 /026 09 15 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
cii 2 ❑ 2 23 81 ,51 /026 09 15 ❑PM ❑Construction
*
R 3 ❑ ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ®AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Sinclair. Dorotea 11-901-A 436000711 81 /51 /026 09 17 ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM 30
t 2 El ARREST NAME 81 /51 /026 09 59 MPM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
436-Lagodzinski. Brian 201 91 , 21 /026 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
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or A
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
IT 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
I- }____A___.-I ,vrm • - i. } } } transportingemployees
p y ployment(example:employee P71
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including y}--- ----; uNts - •} } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
J
t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
�I u^f+ placarding(example:placards will be displayed on the vehicle). D
CARRIERADDRESS NAME
'nZ
r r T 1 r- -1 — . . . . -
V)
0
CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __ USDOT NO. ILCC NO. rn
PCI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
71
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE