HomeMy WebLinkAbout2026-00052743 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 Mil 1 II I flfl
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202612026-00052743 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mW HIGHLAND AVE El In08:27
® ❑ RELATED ®Y 0 N 08 31 2026 ®AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W WESTVI EW ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 6 / yr
Kia Motors Cogteltos 2024 00-NONE Q �I 7T OUETOCRASH ❑
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13-UNDER CARRIAGE 10 1 EN
2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH 0 Ea 1 0
H F. Pingree Grove IL 60140 0 1 FIRST CONTACT 12 7 ; _5 *IIYes.SeeSidebar U1
Z 9 G D33764 I L 2027 Ismi
TELEPHONE
IL D KNDEUCAA2R7628780 Progressive El ®N U2 r 1 R
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same 876419501 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 2 0
Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
!1 9$7 Honda Passport 2026 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 73
C
o 13-UNDER CARRIAGE
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F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
1 S .. 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 O7 ,=QI OS •IfYes.See Sidebar C
ELGIN Z IL 60124 0 1 DC71587 IL 2026 FIRST 0 fp
D
IL D SFNYF9H35TB071401 Farmers Ins ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 545467705 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOEM (SEX) {SAFT) (AIR) (INJI j(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONEI (EMS) (HOSPITAL)
2 6 08 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 08(31 /2026 08 27 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 28 41 ( 1 ❑PM ❑Construction
Z3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
o ® 11 4 ARREST NAME Jozwiak.Jessica. L. 11-601-Ax 414-1149W ( / El PM SLMT
o N •
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
30
r 2 ❑ ARREST NAME AM
7 ( / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ❑AM Workers present? ❑Y 30
414 Cara. Saul 901 275-Engelke ( / ❑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 -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I N - } r r (example:shuttle or charter bus):or 0
< <----- -•-•; I transporting3. Is d mploned to aeesl5 or fewer in the course of passengers
e e mplanoyment employee a contract
Not TO Scale } r } transporter-usually a van type vehicle or passenger car):(example:r w
L L.___a._. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
® Pe ( P 9 Pe or O
wnt r Nm z—
5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placardingrn(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
- ADDRESS
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 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 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