HomeMy WebLinkAbout2026-00000444 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 101161
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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 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 2026I 2026-00000444 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2
® ❑ RELATED ®Y 0 N 01 03 2026 ®AM ❑YES ®NO U1 -<
N STATE ST Elgin08:55
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W W H I C H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
f T TOWED U1 Q
FOR DAMAGEDAREA(S) FRO
Gomez. Kairo.A. 0 1 /
yr 13-UNDER CARRIAGE 1 !l®FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
10 O DISTRACTED ® 0 U2 0 m
M 2 SYTM IN ENGAGEis-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 76•TOP 3 *Distraction Value 5 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�6 4 COM VEH 0 Ea 1 0
~ ELGIN N I L 60123 B 1 0 FIRST CONTACT 1 O 7 ; _5 *lIYes.See Sidebar U1
Z 3767147B IL 2026 REAR
TELEPHONE
IL D 0 3GCPKSE7OCG193406 Allstate ❑Y ®N U2 1--
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Cervantes,Vanessa 922 702 516 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
yr ,2 C
0 13-UNDER CARRIAGE i FIRE ❑ ® U2
c
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOPO3 * X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 91 6 i;:-O COM VEH ❑ ® Ut CO
F„ FIRST CONTACT 11 O _�-`-O••IrYes.See Sidebar
ELGIN IL 60123 0 1 0 BC99YR FL 2026REAR
M
FL D 0 SXYPG4A31 GG075885 USAA Casualty ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 00345 63 63C BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND
❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 01 ,03 l2026 08 55 ®❑pM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 0 25 25 01 r 03 ,2026 08 57 ❑PM 0 Construction >E
R 3 ❑ ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ®AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Gomez, Kairo,A. 11-306 471000571 01,10 l2026 09 01 ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
AM U1 00
t 2 ❑ 1 1 4 ARREST NAME 01 103 l2026 09 38 [�PM 0 Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 00
471-Evans, Lakysha 601 02 , 10,2026 09 00 0 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 -' r INDICATE NORTH combination)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
r r 2 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I- <.- -A----' gg ' of
M1 c } r } transporting
-usually a van type vehicle or passenger
employment ge (example:o employee
r
L }-----}----; �, - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. ,303
—r
-1 i-' for direct compensation(example:large van used for specific purpose):or
L L____a....� — — — 3r 34- 8� I. t 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
— — r � t -I
/' `T'I CARRIER NAME Z
0
W.7HIghland7Ave. :.II ADDRESS D
IIil fff rn
i +'i t CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scam I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 - USDOT NO. ILCC NO. m
m
XI
' Source of above z
'
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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 White
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