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HomeMy WebLinkAbout2026-00061438 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III III 11 IIII UHI U� I� liii flU1 U 0000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X 03925 u, 1 U21 3 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U1 3 U2 1 .P0119* 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 51,500 El NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash El AMENDED YR 202612026-00061438 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn E CHICAGO ST El In 11:34 ® ❑ RELATED ®Y 0 N 10 09 2026 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W SHALES PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD El STOPPED U2 —I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER t] PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NIAV 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 8 / yr 13-UNDER CARRIAGE ©' O- FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED ❑ ga U2 2 m F 2 5 El ®SNE❑ n is-OTHER UNK VEH. ATCRASHIN n ENGAGED 99-UNKNOWN 016 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1 a �i COM VEH 0 El 1 0 F. FIRST CONTACT 1 7 --. _;__5 *IIYes.See Sidebar U1 Z Schamburg IL A 1 0 AH 14233 IL 2027 Is TELEPHONE IL D 0 KMHDU46D19U691466 State Farm ❑Y ICI N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Sultana.Sartaj 3889769-SFP-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D St.Alexius Medical Center ❑Y El 2 ou m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAv 0 NO., 0 DV CIRCLE NUMBER(S) U1 /1 9 6 3 Nissan Pathfinder 2005 00-NONE 0. Q!'-O DUE TO CRASH rg D 2 x o y Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraellen Value 0 POINT OF 8 i1�I 4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B _5 •If Yes.See Sidebar — Hanover Park IL 60133 A 1 0 EP27329 IL 2027 I 0 N IL D 0 5N 1 AR18W75C734788 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 2500094-5FP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < St.Alexius Medical Center RESPONDER u1 = {UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL) :A / / UI 1 D / / 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 10,91 /026 11 34 ®❑PM in a Work Zone? ®N DIRP co 1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 v 2 0 2 2 10/91 /026 11 34 ❑PM ❑Construction " 3 0 ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 3 z J ®AM ❑Maintenance U2 -a, ARREST NAME Abedi.Syeda 11-901 S1582000001 10/91 /026 11 47 ❑PM SLMT 1 ® ❑Utility11 4 0 CITATIONS ISSUED PENDING o NSECTION CITATION NO. ROAD CLEARANCE TIME 0 AM t 2 0 ARREST NAME 10/9/ /026 12 12 ®PM ElUnknown work zone type U1 40 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1582-Rojas.Sinuhe 302 275-Engelke 11 , 17/2026 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 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 INDICATE NORTH combination):or .Z-1 Not To Bathe ' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r (example:shuttle or charter bus):or 0 Shales?Pkwy. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O N } } } transporting employees In the course of their employment(example:employee 73 E.7ChICeg075t transporter-usually a van type vehicle or passenger car):or co C L L.___a__-_J 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or t L L____a____. any t 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m CID s placarding(example:placards will be displayed on the vehicle). > � s _ j urdtt i. i. D CARRIER NAME \ - .. ADDRESS D w C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------4. - USDOT NO. ILCC NO. m 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 E 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 LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/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 ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE