HomeMy WebLinkAbout2024-00072047 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II IIIIII 01100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 13
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202412024-00072047 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 '1
1407 TIMBER DR El In09:00
® ❑ RELATED ❑Y ®N 11 13 2024 ®AM ❑YES ®NO U1 —<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION M_
COUNTY PROPERTY ®Y ❑N DOORING ❑V #OF MOTOR IR SLOW Cl)
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER 0 PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES ❑NIA/ ❑ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 7 /
1 9 9 7 Peterbilt Moto�76o. 2001 �00-NONE 11_ t2 I!_1 DUE TO CRASH ❑ VI E
�.:!UNDER CARRIAGE p . 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SY4 ❑Y ElM DUNK VEH. 0 AT CRASH IN 0 is-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;i�s 4 COM VEH Il 0 1 00
H 1- FridleyM N 55421 0 1 0 FIRST CONTACT 13 7 : _5 *If Yes.See Sidebar U,
Z PAV3911 M N 2025 REAR
TELEPHONE
MN 7 1XP5DR9X61D538872 Sentry Ins Co ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
99 9 Zumba Transportation A0160299001 1 rn
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
20 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 i v 0 Dv
yr 12 _ 71
o 13-UNDER CARRIAGE 10.i :., FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�=1-.:-5 COM•I sVEH See •Sidebar❑ ❑ C
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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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 2 SRS Building Supply Curb 11 ,13 ,2024 09 01 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 ,,
63- 2 ❑ 1407 TIMBER DR ELGIN IL 60123 20 20 11 13 2024 09 02
t
! ! ❑PM. ❑Construction *
Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ®AM ❑Maintenance U2
ARREST NAME 11,13/2024 09 07 ❑PM
o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME El
t 2 El ARREST NAME 11 r 13 /2024 03 10 0 PM El Unknown work zone type U1 0 AM
20
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present? ❑
495-Sjodir.Jacob 501 404 Duffy , / ❑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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --1 -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. - } (example:shuttle or charter bus):or
IN•befilX W.,
L A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L i l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Zumba Transportation Inc. z
,.....r.m. - ADDRESS 614 E 82ND ST O
T.
CITY/STATE/ZIP Bloomington 1 MN 155420 w
Not To Scale ( i. i. i. i. MOTOR CARR.ID El Interstate ❑ Intrastate 5
I I T I 0 Not in Comm./Gout. 0 Not in Comm./Other
i----------1 - USDOT NO. 1729334 ILCC NO. rn
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ® No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
❑ Yes NI No ElUnknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes ®No ❑Unknown Out of Service ❑Yes ®No 7
MCS ❑Yes ®No 0 Unknown Out of Service ❑Yes ®No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAEP 0 Yes ®No 2
TRAILER VIN 1 1 RNF48A26CR024913 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ® 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 48 ft. 2 ft. Z
Yellow
u 1 TOWED TOTAL VEHICLE LENGTH 72 ft. NO.OF AXLES 5
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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. 4 CARGO BODY TYPE 4 LOAD TYPE 2