HomeMy WebLinkAbout2026-00052813 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 61a36
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash
0 AMENDED YR 202612026-00052813 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED 0 Y ®N 08 31 2026 ❑AM ❑YES ®
PRIVATE NO U1
N RANDALL RD Elgin mo /day/yr 01:30 ®PM FLOW CONDITION m
Ef10q0!MI N E O W Holmes Rd COUNTY PROPERTY ❑Y Igl N DOORING El #OF MOTOR 0 SLOW 1 C/)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18: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 5 C)
0 9 /
yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 5 <<T1
M 2 SY n 15-OTHER
5 ❑Y ONM❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 5 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 4 COM VEH 0 El 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 12 7_;1 __5 *IrYes.See Sidebar U1
Z R540387 IL 2026 REAR
TELEPHONE
IL D JM3KE2CEOD0162513 Geico ❑Y ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 4566 12 17 47 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv ❑NCV 0 DV
Yr 2 0 0 3 Lexus ES300 2002 00-NONE ,�_"1 t2..-_, DUE TO CRASH ❑ Ig 2
o 13-UNDERCARRIAGE ta;l 2 FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistraclIon Value 9
POINT OF 8 i 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -II 5 1:_
FIRST CONTACT 6 Y__{_O ._5 ••It Yes.See Sidebar
BARTLETT IL 60103 0 1 0 BH81745 IL 2027 REAR 0
IL D JTHBF30G920069423 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Koslovich. Marco 856973796 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER® U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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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 81 , 11 ,026 01 31 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 41 11 , ) ❑PM ❑Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Essex. Michael. E. 11-710-A 327003444 / / ❑PM SLMT
o N 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0• Utility
r 2 El45
ARREST NAMEAM
7 ❑❑PM ❑Unknown work zone type U1
/ /
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 45
327-Hromadka.Scott 502 275-Engelke 91 , 21 ,026 09 00 ❑PM Workers present? ®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 -<
c ` --I -' r n INDICATE NORTH combination):or —I
4. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N I I - r (example:shuttle or charter bus):or 0
I i it ^';3
3. Is designed to carry 15 or fewer passengers and operated by a contract carver O
-- I - . - . transporting employees in the course of their employment(example:employee X
7.' n transporter-usually a van type vehicle or passenger car):or CO
L }-----}----. 1 al - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
for direct compensation(example:large van used for specific purose):or
L L____a____� �l t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires 'D
I Im
I' I placarding(example:placards will be displayed on the vehicle). ;p
--
- CARRIER NAME —1
Z
ADDRESS 0
I I J . .
Not To Scale CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- -': - USDOT NO. ILCC NO. rn
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.
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 M
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Beige
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Mies/Impound Lot Garage . 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