HomeMy WebLinkAbout2024-00058663 , l Ill
ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii Ill
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553%5
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE •
1
D NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00058663 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 8 'T'I
HOPPS RD Elgin ID
®Y ❑N 09 13 2024 12:02 ❑AM ❑YES ®NO U1 .<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
I&DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EOUES 0 rev ❑r)cv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
dl6 2016
FOR DAMAGEDAREA(S) FRONT_ TOWED U1
NAME(LAST,FIRST,M) mo day yr Kenworth Mot ck Co NONE 11 12 1 DUE TO CRASH ❑ ® E
ZEPEDA- NORBERTO / J
13-UNDER CARRIAGE 10 1 .r 2 FIRE 0 ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Igl U2 m
958 S LIBERTY ST M SYTM❑Y ®S NE❑UNK VEH. O AT CRASH D O ®-UNKNOWN 9 16-TOP 3 ,Distraction Value ALGN =
CITY
PLATE NO. STATE YEAR POINT OF 8 it 6 ii 4 COM VEH 0 El 1 n
jL FIRST CONTACT 16 7. tl___,.._5 *If Yes,See Sidebar U1 0
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1XKYA48X8GJ496702 LIBERTY MUTUAL INSURANCE ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a FEDEX FREIGHT INC. 016227418 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o RESPONDER l 7306 N BAKER RD. FREEMONT. IN .46737 (386)956-1079 VEHU GI
GI
0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1
98 m
a / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi 1 DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 73
c 13-UNDER CARRIAGE 10 I 11 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPOR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value U1 0 -
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II a I_5 CIOMe63eeSideba❑ ❑ C
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPONDER
YOD NR U, _
(UNIT) (SEAT) (DOB) ISEXI ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)r(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) C)
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M
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#OCCS y
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 4 METRONET FIBER WIRE 09/13 /2024 12 02 ®AM
ina Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 6
2 ❑ 20 S DUGAN RD SUGAR GROVE 60554 18 18
II , ! , 0 PM ❑Construction *
or 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
a ARREST NAME / / 0 PM SLMT
o U 1 ❑ 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N B AM30
2 El ARREST NAME r / pp1 ❑Unknown work zone type Ut
T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ElY
244-Blomberg. Michael 702 275-Engelke , , p 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
0
} A CMV is defined as any motor vehicle used to transport passengers or property and. Z
r- -r- - 4 , 4 r r r r r 1 I . r
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
' r • ; i ; i- r r ' i i INDICATE NORTH combination).or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' ._ I ', ! i. ._ ' ' '. ', ' I ` r r r (example'.shuttle or charter bus)-or n
S
; I • I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------'-----• + + • : - -, 1 1 1 i } - t transporting employees in the course of their employment(example.employee ,3
transporter-usually a van type vehicle or passenger car).or 03
' r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver,
9 Po P 9 N
for direct compensation(example:large van used for specific purpose).or O
i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
m13
placarding(example placards will be displayed on the vehicle)
X.
. `
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP O
• . ^ MOTOR CARR ID ❑ Interstate El Intrastate
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
G
r-----.-----, r r r r r----, i USDOT NO ILCC NO. m
X
•
, Source of above z
•
. If Yes Name on placard 0
4 digit UN NO. 1 digit Hazard class No P3
73
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown E
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash% p
❑ Yes No ❑ Unknown C
Was a driver/vehicle Examination Report Form completed? r.
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
z
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
White
-
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 TOWED BY/TO:
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE