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HomeMy WebLinkAbout2024-00073400 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 010111100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403645535 u, 1 U2 1 1 2 U1 1 U2 U, 1 1_12 U, 1 U2 5 4 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00073400 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 20 2024 ®AM ❑YES ®NO U1 -< ROUTE 20 HWY Elgin mo /day/yr 05:01 ❑PM FLOW CONDITION m OO 1C.'J!MI N E S © North Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl) 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 gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 7 / yr Van Leeuwen. Kevin.J. Dodge Ram 1500(pickup) 2017 00-NONE © 12 - , DUE TO CRASH ® ❑ _ 13-UNDER CARRIAGE ) 2 FIRE ❑ alC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 m M I 2 SY4 ❑Y ®SNEM IN n❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16•TOP 3 *Distraction Value ALGN - r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a �i 4 COIN VEH 0 Ea 1 0 0 Hampshire IL 60140 0 1 FIRST CONTACT 11 7_:, __5 *IIYes.SeeSidebar U1 Z P 2869520B IL 2024 REAR TELEPHONE IL D 0 3C6RR7LT2HG784529 Progressive Insurance ❑v ®N U2 ni 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same 9747677252 2 m o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 rg- ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NUV 0 i v 0 Dv yr 12 _ 71 .. 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *°is/rec) n Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:-6 C•IO e1sVEH See •Sidebar❑ 0 C CO I� ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YDNDER❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m / / ##occs > Pj / 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 15 1 Department of Natural Resources a deer 11 ,20 ,2024 05 00 ®❑pM AM in a Work Zone? Igi N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 ;, t 2 0 1 NATURAL RESOURCES WA5'pringfieldL 62702 21 15 , , ❑AM ❑Construction * ZJ 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 a ARREST NAME / / ❑PM ' o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT SECTION CITATION NO. ROAD CLEARANCE TIME o N El AM U, 55 r 2 ❑ ARREST NAME 1 1,20 ,2024 05 30 [M PM ❑Unknown work zone type n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 Y 2 3 0 - ❑AM Workers present? 469-Taylor,Jonathan 801 , , ❑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 0I U 8 Ratru 720 ADDITIONAL UNITS FORMS. A CMV is defined as any motor vehicle used to transport passengers or property and: Z I _-Not.7b S961. • 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< TT ) INDICATE NORTH combination):or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ (example:shuttle or charter bus):or ` A — r , r 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O } } } transporting employees in the course of their employment(example:employee X i " transporter-usually a van type vehicle or passenger car):or co __ -_ Deer7POI I. } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)g for direct compensation(example:large van used for specific purpose):or O __ i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III placarding(example:placards will be displayed on the vehicle). ;p —1 CARRIER NAME Z ADDRESS D ‘grA CITY/STATE/ZIP 0 g - i. i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate 1 1 T 1 I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown 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 Xl IDOT PERMIT NO. WIDELOAD'7 ❑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' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE