HomeMy WebLinkAbout2024-00078635 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
I01101100 011 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403661527
u, 1 U21 1 1 4 U, 8 U2 1 U, 1 u2 1 U, 1 u2 1 5 12 U, 13 U2 1 �K P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00078635 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 12 15 2024 ❑AM ❑YES ®NO U1
N MCLEAN BLVD Elgin mo /day/yr 03:55 ®PM FLOW CONDITION m
I0 ®!MI N E OS W Demmond St COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGED AREA(S) FROPtf TOWED U1 Q
Adams.Tangala.T. 0 8
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 SY n 15-OTHER
4 ❑Y ®SNE❑UNK VEH. AT CRASIN n H 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �;il 6 �i,4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 8 7_; __5 *II Yes.See Sidebar U1
Z EB11311 IL 2025 E
TELEPHONE
IL Other 1 C3CCBAB7CN295285 NIA ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
CQ
Same NIA 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 c
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 RGV 0 DV
1 9 yf 7 Honda Accord 2011 00-NONE ,i ' t2 -Y1 DUE TO CRASH 0 (� 2 x
_ 13-UNDER CARRIAGE I1.J FIRE 0 ® U2
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 19-TOP 3 X
❑Y Ig N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 i,_i COM VEH D ® U1 CO
FIRST CONTACT 1 Y _, _5 •IfYes.See Sidebar
1.-. ELGIN Z I L 60123 0 1 0 EW65727 I L 2025 REAR C
M
IL A 7 1 HGCM66897A035465 Magnum ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same PPQ0038076 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 12,15 r2024 03 55 ®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 �
o"
2 ❑ 08 20 ) ) El PM ❑Construction *
R , 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
— U2
a, ARREST NAME Adams.Tangala.T. 3-707 752495 r r ❑❑PM ❑Maintenance SLMT
U 1 ® 1 1 1 CITATIONS ISSUED ❑PENDING TIME • ❑Utility
o N SECTION CITATION NO. ROAD CLEARANCE AM
t 2 ❑ ARREST NAME Adams.Tangala.T. 11-709-A 752494 r r a PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1534-Santiago.Jorge 602 01 ,02/2025 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: D
INot To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }___-r----; ( INDICATE NORTH combination):or
p0
LBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
NJ _ (example:shuttle or charter bus):or
p T,
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}----------i `
} } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L L.___a____. °""tl01° 4. Isusedordesinatedtotrans rtbetween9and15passengers,includingthedriver. C
} } } for direct compensation(examp large van used for speific purose):or
L a-__-. - � i I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
O
.D
placarding(example:placards will be displayed on the vehicle). m
CARRIER NAME Z
ADDRESS 0
V)1 g
G I•I n
CITY/STATE/ZIP', I
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I lew i ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. own tank)? 0 Yes 0 No 0 UnknownT.
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
71
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
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE