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HomeMy WebLinkAbout2024-00064967 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III (III (IIIIII II 111111111111 1111101 11011111 III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035°3591 u, 1 U2 1 1 1 1 U1 5 U2 1 U, 1 U2 1 Ut 1 U2 1 1 12 U1 13 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.5000 NOT ON S®ON SCENE 2 VEHICLE/PROPERTY ill OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00064967 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 21 71 CONGDON AVE Elgin ID ❑Y coN 10 11 2024 10:18 ®AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W BLACKHAWK ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O Peterbilt MotoffiBo. 2019 00-NONE DUE TO CRASH r J NAME(LAST FIRST,M) , Edgar mo day yr 11_I 1$ D ❑ ® E 13-UNDER CARRIAGE FIRE 0 ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 1l U2 2 m 24410 KISHWAUKEE VALLEY RD M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UNKNOWN THER 9 16-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 it i 4 COM VEH 0 El 1 C) jL FIRST CONTACT 1 7 :t a -5 "If Yes,See Sidebar U1 0 Z 2NP3WOX6KM263700 COUNTRY MUTUAL INSURANCE ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Schroeder Asphalt Se AV9181578 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L RESPONDER PO BO 831 . H U NTLEY. I L,60142 (815)923-4380 VEHU1 0 ®cRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 14 m m / J FOR DAMAGED AREA(S) FROM TOWED CRasH Y N S Ka alka-Szczepan 1 2 2 6 1 9 7 6 Mercedes Berl printer 2019 00-NONE Q' 1 ❑ ® 98 —I NAME(LAST,FIRST,M) P P mo day yr 12 I'- xi C v 13-UNDER CARRIAGE 0) 2 FIRE ❑ Ill U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 IN SPDR n a 707 OKLAHOMA WAY M SYSTEM IN O ENGAGED 0 15-OTHER 016-TOP 3 9 0 X ❑Y ® ID UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE Na STATE YEAR POF FIRST CNT ONTACT 10 7. —6 5 CUOYer,VSee Sidebar ® U1to C H Elk Grove IL 60007 0 DRA6196 FL 2025 0 fp TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)965-7170 K142-7807-6367 IL C 0 WD4PF1CDOKP148280 PROGRESSIVE ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 984380343 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 YOND I N Same Ut = (UNITE (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m - #OCCS > /• / U1 1 73 Ito I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ®Y U2 Z N ® 11 1 10/1 1 /2024 10 18 ❑pM in a Work Zone? ❑N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 C) T 2 ❑ 20 03 ! / 0 PM in Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Dominguez. Edgar 11-708 456-414w / / ❑PM SLMT o U CITATIONS ISSUEDPENDING • ROAD CLEARANCE TIME 0 Utility o N ❑ 0 SECTION CITATION NO. AM 40 2 ❑ ARREST NAME 10/11 /2024 10 45 El pm0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 40 456-Romalo,Carmine 201 275-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. r 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 -< r i ; i r r , , i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` 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 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers 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) 11 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir '- DO ILCC NO. m U N XI , Source of above Z . ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D 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 to 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 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White Blue - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE