HomeMy WebLinkAbout2026-00061949 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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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 ❑5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 202612026-00061949 VENT
ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mRT20 RELATED ❑Y ®N 10 11 2026 08:48 12,— ❑YES ®NO U1
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m
10 /MI N E S W Shannon PkwyCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 fA
® O Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRO T TOWED U1 O
NAME(LAST,FIRST,M) Kolich.Gregory.J. 0 6 /
yr 13-UNDERCARRIAGE 1a.I 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 76•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL S 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60124 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1
Z 2706079B IL 2027 REAR
TELEPHONE
IL D 0 1 GCGTBEN2K1312081 Progressive ❑v ®N U2 Ill . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 976095866 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 NMV 0 NCV 0 CIRCLE NUMBER(S) U1
DV
yr
/1 9 5 5 Chevrolet Trax 2025 00-NONE ,�_` 12 "_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE ( 2 FIRE ❑ ® U2 C
P.
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y MN DUNK VEH. AT CRASH 99-UNKNOWN *Oistraclion Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 1 O Y .5 •If Yes.See Sidebar
H ELGIN IL 60123 0 1 0 EJ79607 IL 2026 I0 C
IL D 0 KL77LFEP7SC080958 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 4108354SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 03 /
/ / UI 2 D:A
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
u 1 ® 11 1 10,11 /2026 08 48 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 20 99 , / ❑PM ❑Construction >E
Z 3 0 ]$g CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a u ® 11 1 ARREST NAME Kolich.Gregory.J. 11-709-A S1519-00056 / / El PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
o N 0 AM 45
r 2 El ARREST NAME Kolich.Gregory.J. 11-402-A S1519-000564 , / pM Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1524-Silva,Jose 801 337-Thompson 10 ,28,2026 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 -<
c --I- armonrva,x INDICATE NORTH combination):or —I
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I [ - (example:shuttle or charter bus):or 0
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I }} } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
__ u I.
! . •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
- — — — for direct compensation(example:large van used for specific purpose):or O
umas l. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 I placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 'n
cCITY/STATE/ZIPng
Not To Scale ! - i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
' Source of above z
. 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
White Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE