HomeMy WebLinkAbout2026-00021435 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110 11111100111111 �10000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00420655
u1 1 U21 3 4 2 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 4 10 U, 4 U2 �K P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202612026-00021435 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S MCLEAN BLVD Elgin 08:11
® ❑ RELATED ❑Y ®N 04 17 2026 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W LILLIANST COUNTY PROPERTY ❑Y ® N DOORING ID #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
T TOWED U1 O
Gomez.
yr 13-UNDER CARRIAGE 1a.) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ Ea U2 4 rn
F 2 SYTM 4 ❑Y ❑SNEEl UNK VEH. 9 ATCRASHD 9 99-U15-UNKNOWN THER9 16•TrOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *IIYes.See Sidebar Ut
Z EH45756 IL 2026 E
TELEPHONE
IL D 5NMS23AD7LH300631 State Farm ❑Y ®N U2 1—
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
Gomez Vega.Salvador 0771796-SFP-13 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER
RESPONDER
2
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 o v ❑NCv 0 Dv
2 0 0 7 Dodge Caravan(inc Grand)2018 00-NONE ,1"j 12..-_, DUETO CRASH ❑ !g 2 x
o 13-UNDER CARRIAGE �a} 2 FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X
❑Y ❑N IN UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI 6 I',_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 f :j_O ._5 •If Yes.See Sidebar
~ ELGIN IL 60123 0 1 0 CX18966 IL 2026 AR 0 N
M
IL D 2C4RDGBG7JR137636 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Jaimes.Abelina 986386156 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
ui =
iUNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 4 04 /
/ / UI 3 :A
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 1 04,17 /2026 08 11 ®AM in a Work Zone? ®N DIRP co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C1
T
o",
2 0 2 99 1 1 0 PM• 0 Construction
Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
-a, ARREST NAME Gomez.Ashley 11-901-A W1552000339 r r El PM 1 ® 1 1 1 0CITATIONS ISSUED ❑PENDING SLMT
o uSECTION CITATION NO. ROAD CLEARANCE TIME
0
Utilit y
t 2 El ARREST NAME 04 r 17 12026 08 12 ®PM 0 Unknown work zone type U1 El AM 40
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1552-Thompson.Ahmad Rashad 602 337-Thompson , / ❑❑PM Am Workers present? ®N U2 40
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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. 1 ..._.... J transporting edmployeeslin5 hecourseeo theire rsmployment example:employeener
} } }
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____.: L L L ...._-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zt
--I
CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 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
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE