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HomeMy WebLinkAbout2026-00061897 (3) ILLINOIS TRAFFIC CRASH REPORT Sheet 5 of 8 Sheets HUI III 11 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY u, 1 U21 1 1 1 U1 1 U2 1 U1 1 U2 1 U1 1 U2 1 1 14 U, 1 u2 1 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2026I 2026-00061897 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -1 ® ❑ RELATED PRIVATE ❑Y ®N 10 11 2026 DAM ❑YES ®NO U1 -< RANDALL RD Elgin mo /day/yr 01:00 ®PM FLOW CONDITION III 01 OCO,MI O E S W Fletcher Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 IYg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) FOR DAMAGEDAREA(S) FROM TOWED U1 Q NAME(LAST,FIRST,M) KU LESZA. M ICHAL.S. 0 mo 3 / 1 9 8 9 Volkswagen Golf 2022 00-NONE „_' ©' DUE TO CRASH ® ❑ 13-UNDER CARRIAGE FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 -O DISTRACTED ❑ ]$I U2 4 I TIC ) M 2 THER 8 ❑Y ®S NE❑UNK VEH. O AT CRASH O 99-Uis-UNKNOWN 9 16-TOPO ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 it®COM VEH 0 LK 1 0 H 1- PINGREE GROVE IL 60140 B 1 0 FIRST CONTACT 1 r:1 -L9 .ir Yes.See Sidebar U1 0 ZFB50225 IL 2026 TELEPHONE IL D 0 WVWFB7CDONW148004 STATE FARM ❑Y 0 N U2 r Ill 'I n 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 2914164-SFP-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER yr Q 12�,Q o 13-UNDER CARRIAGE I f1.. 2 FIRE 0 ® U2 C c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istraction value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- 1 6 I( 4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 Y .6 •(ryes.See Sidebar H ELGIN IL 60123 B 1 0 CU23246 IL 2026 I 0 Si)C IL D 0 5FNYF4H57BB022753 ALL STATE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Soto. Maritza 932929880 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (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 1 10,11 ,2026 01 00 0 AM in a Work Zone? ®N DIRP co T 2 0 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) v 10,11 ,2026 O1 02 ®PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 ARREST NAME 10,11 /2026 01 10 ®PM 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING Utilit SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ y t 2 El ARREST NAME 10 r 1 1 12026 04 00 0 PM 0 Unknown work zone type U1 50 0 AM n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 451-Nisivaco. Russell 901 320-Cox 11 , 10,2026 01 30 El 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. 0 A CMV is defined as for vehxae used to tra and: r ----,5-••--, ; any mo nsport passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - } i.-- -I-- --; } } } r -, , ; ; ; ( INDICATE NORTH combination):or —I X1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' , } (example:shuttle or charter bus):or x 3. Is . L.___A_. 1 i. <--_... . J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } • � . transporter-usually a van type vehicle or passenger car):or co < <.__-a-_--, , l• < '---_-a-___� , , , , 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 0 L L___-a____.I L L L L.__-..i._ 1 t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z i. ADDRESS 0 th CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate O ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m 73 Source of above z ) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m Z GVWR/GCWR 1 El <10,000 El10,000-26,000 El >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. P3 Xl 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? 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 73 IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 5 COLOR U 6 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White Silver u 5 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 6 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