HomeMy WebLinkAbout2026-00055735 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00055735 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y ❑N 09 13 2026 ®AM ❑YES ®NO U1
VANTAGE DR Elgin09:16
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT l MI N E S W NORTHWEST PKWY COUNTY PROPERTY El ® N DOORING El #OF MOTOR El SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ICU 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
T TOWED U1 O
NAME(LAST,FIRST,M) Hugo. mo yr
Romo Gutierrez. A. Dodge Durango 2024 00-NONE „ • 12 , DUE TOCRASH ® ❑
13-UNDERCARRIAGE 10 ` 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SYST6 ❑Y ONEM❑UNK VEH. O AT CRASH 0 99-UUTHER NKNOWN Ole•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL B �i 4 COM VEH 0 j$J 1 0
~ Dekalb IL 60115 B 1 0 FIRST CONTACT 9 7 : __5 *IIYes.SeeSidebar U1
Z FW53500 I L 2027 REAR
TELEPHONE
IL C 0 1 C4SDJCT1 RC221210 StateFarm ❑Y Igl N U2 m
.9 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 3930785SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KOV 0 DV
/1 9 8 0 Subaru Legacy 2025 00-NONE ,i ' t2...0 DUE TO CRASH D
2
0 13-UNDER CARRIAGE 10 2 FIRE 0 ® U2 C
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
POINT OF S i1 �I COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5
FIRST CONTACT 1 Y _, _5 •)ryes.See Sidebar
= PINGREE GROVE dc IL 60140 B 1 0 8779188 IL 2027 I 9 (Cl)
IL D 0 4S3BWAC69S3016406 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Devries. Darren.C. 954126380 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 3 06 /
2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 1 09/13 /2026 09 16 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
✓ 2 ❑ 25 99 09,13 /2026 09 22 El PM El Construction >E
4
R O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ®AM ❑Maintenance U2
a ® 11 1 ARREST NAME Romo Gutierrez. Hugo.A. 11-1204-B 1530000864 09/13/2026 09 33 ❑pM SLMT
o Nu ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM u, 15
t 2 El ARREST NAME 09/13 /2026 09 58 0 PM 0 Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 901 320-Cox 10 /06/2026 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
N
1 u1! 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }--__r-_--; - INDICATE NORTH combination):or
P3
Not To Scale1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
- } (example:shuttle or charter bus):or
X
L A 3. Is designetl to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee
L.- l• transporter-usually a van type vehicle or passenger car):or w
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4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} } for direct compensation(example:large van used for cific ur mdudi the driver,
Pe ( P 9 Pe purpose):or O
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L____a____. _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
.,th a prn
n{Ot t�7W@St?r k�/}/ placarding(example:placards will be displayed on the vehicle). X/
Unit 2 Iwt I,
t CARRIER NAME Z
ADDRESS 0
Unit 1 -
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CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
1 I r 1 III° 0 Not in Comm./Govt. 0 Not in Comm./Other 0
""Y""" Vantage?Dr r r ILCCNO.USDOT NO
Source of above XI
. • m
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 0 No 0 Unknown M
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' -n
TRAILER 1 0 0 0 Z
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TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 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 2 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