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HomeMy WebLinkAbout2024-00061886 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III )III IIIIIII II 11111111111 110111111111 lUll Ill I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O356?D52' u, 1 U2 1 1 8 U1 9 U2 1 U, 1 U2 UI 1 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061886 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 •T1 SWEETFLAG CIR El ❑ Elgin RELATED ❑Y coN 09 27 2024 1125 ®AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ❑PM FLOW CONDITION m Q( /MI N O E s w Hedgerow Dr 'COUNTY PROPERTY El ®N DOORING ❑'' #OF MOTOR ❑SLOW 15 co ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 8 / 2 4 /1 9 7 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 no, L. Freightliner Cddpk 2017 00-NONE 11 , DUE TO CRASH ❑ NAME(LAST,FIRST,M) g mo day yr 12 ,3-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 21 10 • O DISTRACTED 0 El U2 2 m 10730 US HIGHWAY 20 M ❑Y ESYlM❑UNK VEH. O AT CRASH D O 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 6 4 COM VEH ® ❑ 4 0 3AKJGBDV3HSJC8754 Pennsylvania Lumbermens M ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Carpenter Contractor 05K0020924 5 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER Y El N 2340 NEWBURG RD. BELVIDERE. IL, 61008 (815)544-1699 VEHU 0 m 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 20 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N mo day yr Ford Explorer 2017 00-NONE 1 12 ,_t73 NAME(LAST,FIRST,M) DUE TO CRASH ❑ ® 1 c 13-UNDERCARRIAGE Oi ! 2 FIRE El El U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 ® SPDR n ® N 'DUNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 0 - ❑Y POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH ❑ ® to C FIRST CONTACT 11 7__.1 8_S •UVes,See Sidebar CF21486 I L 2025 REAR 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FM5K7089HG E34568 Kemper ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Cruz Martinez.Joaquin 12AU001567594 BAC ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y NR 806 S OLTENDORF RD.Streamwood. IL.60107 (901)376-3327 U1 = (UNIT) (SEAT) (DOBi )SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 r m / / - #OCCS ' D / / U1 1 73 / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N ® 18 1 09/27 /2024 11 25 ❑pM in a Work Zone? ®N DIRP co I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 5 C) T 2 0 12 30 ! / 0 PM El Construction * t N 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 7 Q ® 11 1 ARREST NAME / / El PM 0 Utility SLMT p U ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ',3N B AM OO 1,1 T 2 0 ARREST NAME 1 / ptil ❑Unknown work zone type Ut • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 00 319-Ross..Adam 801 272-Bajak , / 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. 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS } 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 truckrtrailer -< i ; i r r ' i i combination) or —I INDICATE NORTH 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----t-----• I I • ' ' 1 1 1 i 't } - i• transporting employees in the course of their employment(example.employee 73 transporter-usually a van type vehicle or passenger car).or w 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 placarding(example placards will be displayed on the vehicle) 71 M CARRIER NAME Carpenter Contractors of America Inc Z .. ADDRESS 2340 NEWBURG RD r. CITY/STATE/ZIP BELVIDEREIIL161008 . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q r---- ----, , r r r r r -, - DO 855033 ILCC NO. m US T NO Xl , Source of above Z . Form Number m IDOT PERMIT NO WIDELOAD? ❑Yes ®No 2 ' TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft 2 ft. Z White Blue - u 1 TOWED TOTAL VEHICLE LENGTH Unk ft. NO.OF AXLES 5 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. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG 6 CARGO BODY TYPE 4 LOAD TYPE 2