HomeMy WebLinkAbout2026-00056783 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00 81599-
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2026I 2026-00056783 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 09 18 2026 ®AM ❑YES ®NO U1 -<
E CHICAGO ST Elgin 07:07
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W PHILLIPS LLI PS WAY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 l330Nr TOWED U1 0
Koud onou.Shelter. B. Toyota Corolla 2006 00-NONE „ , DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 1al 2 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ❑ 0U2 2 rrl
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 I,.4 COM VEH 0 Ea 3 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1
Z S379345 IL 2026 REAR
TELEPHONE
IL D 0 JTDBR32E360096028 Progressive El ®N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Koudjonou.Adzowa. L. 968837529 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑i,
!1 9$4 Kia Motors Co►peltos 2023 00-NONE ,t-1 12..`1 DUE TO CRASH ❑ C 2
.. 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI 6 I,,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •If Yes,See Sidebar
= ELGIN IL 60120 B 1 0 DR76134 IL 2026 iEAR 0
IL D 0 KNDERCAA8P7417193 Farmers Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same A7981618050 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
St.Alexius Medical Center RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 02 / F 2 4 0 1 0
m
/ / #OCCS >
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 91 /81 /026 07 07 0 PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
2 14 28 91 !81 /026 07 17 ❑PM ❑Construction
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ®AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Koudjonou.Shelter. B. 11-601 1530000871 91 /81 /026 07 12 ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM U1 40
r 2 El ARREST NAME 91 181 /026 07 41 0 PM El Unknown work zone type
2 2 3 El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 40
1530-Soto.Oscar 302 275-Engelke 10 ! 61 /026 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
ADDITIONAL UNITS FORMS.
r ----r•"--, , 4 ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }----r__--; ll } INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale 1 } (example:shuttle or charter bus):or
< <---- -•- IL transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employee
transporter} } }
transporter-usually a van type vehicle or passenger car):or CO
L l 4. Is used or designated to transport between 9 and 15 passengers,including W
-- -- - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
E?Chicago?St - i. . . i. ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
• placarding(example:placards will be displayed on the vehicle). ;p
t 1
-Unt 1 CARRIER NAME Z
i
ADDRESS 0-
T.
rn
Unit 2 CITY/STATE/ZIP g
1 I MOTOR CARR.ID 0 Interstate 0 Intrastate
r ❑ Not in Comm./Govt. ❑ Not in Comm./Other
T � 0
-_"--- _- Phillips?Way L USDOT NO. ILCC NO. C
XI
Source of above 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 VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Beige White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE