HomeMy WebLinkAbout2026-00058564 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets II I 111 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO0 392976
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INVESTIGATING AGENCY DAMAGE TO ANY El 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 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202612026-00058564 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 09 26 2026 ®AM ❑YES ®NO U1
N STATE ST Elgin10:23
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W WING ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 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 n
0 9 /
yr
Tolczyk. Daniel.J. Chrysler 200 2014 00-NONE „ O , DUE TO CRASH ® ❑
13-UNDER CARRIAGE �a:) 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
M 2 SY8 ❑Y El ®UNK VEH. 9 AT CRASH M IN D 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il S 4 COM VEH 0 Ea 4 0
~ ELGIN I L 60120 B 1 0 FIRST CONTACT 12 7_: _-5 *If Yes.See Sidebar U1
Z DA84831 IL 2025 kfAii
TELEPHONE
IL D 0 1 C3CCCDG9FN615868 USAA General Indemnity Co ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 024848182 7103 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 Nev 0 DV
!2 0 0 7 Toyota Camry 2022 00-NONE ,i_"j Q1.,-_, DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10 i I. 2 FIRE ❑ El U2 C
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❑Y ❑N IN UNK VEH. AT CRASH 99-UNKNOWN *Distract Dn Value ❑ 9 ® U1 9 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i_d!_4 COM VEH
FIRST CONTACT 12 Y�� =5 •If Yes.See Sidebar C
ELGIN IL 60123 B 1 0 FH69332 IL 2025aR 9 fp
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IL D 0 4T1 G 11 AK4N U645442 American Freedom Ins ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 12-2541396-00 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 09,26 /2026 10 23 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 ❑ 2 99 09,26 /2026 10 25 ❑PM ❑Construction >F
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ®AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Tolczyk. Daniel.J. 11-901-A 1538000469 09/26/2026 10 29 ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
AM 30
t 2 El ARREST NAME 09/26 /2026 11 15 MPM 0 Unknown work zone type U,
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1538-Estrada. Leticia 500 360-Yucaitis 11 ,03/2026 01 30 ®PM Workers present? ®N U2 30
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
Not To Scale I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
}
i- -- --I-- --' - r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
' I - 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
' I ~ m. • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
for direct compensation(example:large van used for specific purpose):or O
L Lii
0 L i. i. _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
R y„ 4, — I placarding(example:placards will be displayed on the vehicle). XI
-
$ 2 CARRIER NAME Z
ADDRESS 0I I '' _m. U)
I I CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown 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
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
Black Gray
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 ® Arties/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE