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HomeMy WebLinkAbout2026-00057161 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 Mil 1 II I flfl Oil111111011111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X+ 84667- u, 2 U2 1 1 2 U, 4 U2 1 U, 1 1_12 U, 1 U2 1 5 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 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 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202612026-00057161 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED PRIVATE ❑Y ®N 09 19 2026 ❑AM ❑YES El NO U1 AN NAN DALE DR Elgin mo /day/yr 11:58 ®PM FLOW CONDITION m �O�F !MI O E S W Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 Cl) Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (i DRIVER ID PARKED 0 DRIVERLESS 0 PED CI PEON. 0 EDUES 0 NIA/ 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n FOR DAMAGEDAREA(S) FROM TOWED U1 0NAME(LAST,FIRST,M) g Sayasithmo 1 9 7 9 Nissan Sentra 2017 00-NONE „ • Q , DUE TO CRASH ® ❑ 13-UNDER CARRIAGE FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 0 DISTRACTED 0 0 U2 1 r<rl M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL 6 i,.4 COM VEH 0 Ea 1 0 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7_; __5 *Irves.See Sidebar U1 Z GC73004 IL 2027 REAR TELEPHONE IL 3N 1 CB7AP6HY216886 Allstate ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Same 875484277 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 X m 0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEON. 0 EWES 0 Nuy 0 NOV 0 Dv yr 12 _ 71 o 13-UNDER CARRIAGE 1U 1 2 FIRE ❑ ® U2 C Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.TOP 3 ❑ ® SPDR n ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I 6 .. 4 COM VEH ❑ ® U1 W F,,, FIRST CONTACT 7 Q � .s •It Yes.See Sidebar C GF13173 IL 2016 I 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2G 11 X5SA0G9187817 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 981401972 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPOND❑Y 0N U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 18 1 09,19 /2026 11 58 ®PM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 ❑ 08 19 1 ) 0 PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 —a, ARREST NAME Thongsakounh.Sayasith 11-601-Ax 1548000321 1 r ❑PM SLMT o U 1 ® 11 1 CITATIONS ISSUED 0 PENDING Utility 8igiSECTION •CITATION NO. ROAD CLEARANCE TIME AM• 0 t 2 El ARREST NAME Thongsakounh.Sayasith 11-501-A-1 1548000319 091 20 ,2026 01 15 [M PM ❑Unknown work zone type U1 25 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 25 1 554-Wagener.Vincent 700 10 , 19/2026 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 0 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 -< i- }----r----1 Not ToSeere : - ( INDICATE NORTH combination):or . .. . . p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i nendeie?Dr. - (example:shuttle or charter bus):or r r r X r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O - ------I----; } } } transportingemployees In the course of their employment rter-usually a van type icle or enger < <.___a____J © 1 1 � �used ordesinatedto transport between9 and c5)(ssenptrs,irtclrrdmg the driver, [912?/M ds4Drl-._.'[] !* } } • • for direct compensation(example:large van used for specific purpose):or L l t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M i placarding(example:placards will be displayed on the vehicle). XI -I CARRIER NAME Z ADDRESS 0 V) 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate El Intrastate 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 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 ❑ No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown A 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 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue Silver 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE