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HomeMy WebLinkAbout2024-00059490 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIIIIII II 11111111IllIllHl 101 11111 HI 1111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03555530- u, 1 U21 3 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 U1 3 U2 4 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT LE 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 S VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00059490 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 -Pl N STATE ST ❑Elgin RELATED ®Y ❑N 09 17 2024 07:35 ®AM ❑YES ®No u1 -< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W WEST ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 ECUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRONT TOWED Ut O .J. 0 6 / 1 6 J 1 9 8 7 Toyota RAV4 2013 00-NONE 11 12 i' 1 DUETOCRASH ❑ ® - NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) I,• 2 FIRE ❑ 1$1 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 15 DEVONSHIRE CIR M ❑Y El NSYSTEM❑UNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 6 )Imj 4 COMVEH 0 ® 1 O 2T3DFREV3DW054175 Progressive ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 922642072 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > '' RESPONDER Same VEHU L ❑Y ®N 2 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TO ODCRASH s Oyejobi.Tokunbur-A. 0 6 2 1 1 9 7 8 Chrysler Voyager 2020 00-NONE 0 1 O ❑ ® 2 Xi NAME(LAST,FIRST,M) mo day yr 10 Ojl z FIRE ❑ ® U2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a 978 JEFFERSON SQ G M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y Ig l N DUNK VEH. AT CRASH 99-UNKNOWN Oistract(on Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF to FIRST CONTACTNT O 11 7.'1-6- .5 CUvesVSee Sidebar ® U1 C Elk Grove IL 60007 0 DU72204 IL 2025 ri • 0 fp TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)400-1550 0210-8017-8176 IL D 0 2C4RC1 DGXLR143768 United Equity Ins.Co. ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same PPW1318198 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNIT) (SEAT) (DOB( (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME'((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) - 2 3 12 /1 7/1975 F 2 4 0 1 0 Christine M. Oyejobi/978 JEFFERSON SQ G.Elk Grove.IL.60007 Refused 996 ,- (224)595-5761 _ U2 m / / #OCCS D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N ® 11 1 91 /71 /024 07 35 ❑pM in a Work Zone? El N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 3 a, 2 ❑ 2 2 / J 0 PM ❑Construction N 1 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME Nelson, Michael,J. 11-901 W348-001334 / / El PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N BAM 30 2 0 ARREST NAME r I pp1 ❑Unknown work zone type Ut r(fca T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 348-Rapacz,Jordan 501 272-Bajak r / 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 '. ' t ` ` ' ' 1 ` ` 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------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 • 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----, r r - 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 Gray Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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