HomeMy WebLinkAbout2026-00016939 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 042O 130
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ❑ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202612026-00016939 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ❑Y ®N 03 28 2026 ®AM ❑YES ®NO U1 -<
ANN ST Elgin04:40
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 '
❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 Mlles 0 WIN 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 5 FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
NAME(LAST,FIRST,M) Albarran Gomez.Victor.A. mo General MotorSiQo 2011 00-NONE
DUE TOCRASH ❑/ / yr 0. 12EN
13-UNDER CARRIAGE a I I! 2- FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 9 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 �i COM VEH ❑ Ea 1 0
�- ELGIN I L 60120 0 9 FIRST CONTACT 11 7_:, __-5 *Ir Yes.See Sidebar u1
Z 3037754B IL 2026 REAR
TELEPHONE
IL D 0 1 GTR2U EA8BZ216607 Statefarm ❑Y ign4 U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3513155 SFP 13 9 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER eur 2
0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 vv 0 KCV 0 Dv
yr Chevrolet Trail Blazer 2002 00-NONE 11 '1z .-1 DUE TO CRASH ❑ 2 x
o _ 13-UNDER CARRIAGE FIRE 0 ® U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR n
❑Y ®N D UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value U1 9 -
POINT OF s I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _'._ C.OM VEH ❑ ® C
F„ FIRST CONTACT 11 7 _,r_5 •If Yes,See Sidebar
G404277 IL 2026 I 0 fp
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 G N DT13S222516581 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Caballero.Juan 0803832SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 03,28 /2026 06 44 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 18 99 , , ❑PM, ❑Construction *
1
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Albarran Gomez.Victor.A. 11-404-A 399004495 ! ! El PM SLMT
o N 1 ® 11 1 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM 30
r 2 El ARREST NAME Albarran Gomez.Victor.A. 11-601-Ax 399004496 , ! DI PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 99
399-Kazy-Garey. Daniel 102 337-Thompson 04 ,21 ,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 -<
i- }-- -'-- --' } INDICATE NORTH combination):or -I
i
Not To Scale I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I 0
- } ,. (example:shuttle or charter bus):or 0
A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
m tort,. - } } } transporting employees in the course of their employment(example:employee X
I transporter-usually a van type vehicle or passenger car):or CO
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g po passen rs,includi the driver,
j for direct compensation(example:large van used for specific purpose):or
__ I _ L i. i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
D
•a®m,,,,q,®a CARRIER NAME
R
_ ADDRESS 0inma. D
1 (A
I IO
CITY/STATE/ZIP C)
i.
i.
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------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
Blue Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BYlT6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE