HomeMy WebLinkAbout2025-00017662 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00017662 VENT
ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
RT20 RELATED ®Y 0 N 03 20 2025 08:05 ®AM ❑YES ®NO U1
Elgin PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W HIGHLAND WOODS BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 7 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD El
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lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 uuv 0 ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FROnrr TOWED U1 Q
SKARIAH.SITYJUMON Mitsubishi Outlander 2005 00-NONE 0O i_, DUETOCRASH ® ❑ E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
M 2 5 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i 4 COM VEH 0 j$J 1 0
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HAMPSHIRE I L 60140 0 1 0 FIRST CONTACT 11 7_: __5 *IKYes.See Sidebar U1
Z8335229 IL 2025 REAR
TELEPHONE
IL D JA4LZ31F25U007940 Allstate ❑y ®N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 EAPEN.SNEHA 966432951 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 KKv ❑Dv
1 9 5 4 Trailstar Travel Trailer 2005 00-NONE O, . 12.._, DUE TO CRASH ❑ !g► 21 73
o y Yr 13-UNDER CARRIAGE ta,i 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 916.TOP3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *DistractionValue 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si 6 i.'.,_4 COM VEH ® ❑ U1 CO
F„ FIRST CONTACT 11 7 ,_5 •If Yes.See Sidebar c
ELGIN IL 60124 0 1 0 793931ST IL 2025aR 0 Si)
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IL A 7 1T9FC22B751066844 TRAVERLERS INDEMNITY ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Welch Bros BA4T933086 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT( (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 03,20 ,2025 08 05 ®❑AM in a Work Zone? ®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 �
0 2 0 03 19 , , ❑PM ❑Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a SKARIAH.SHYJUMON 11-1427-H- W486000211 / , PM
-, ARREST NAME ❑
o u ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
45
F 2 ARREST NAME AM
1 r ❑❑PM 0 Unknown work zone type U1
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cf 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
486-Munoz.Jasmine 900 331-Ziegler , / ❑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 -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
:. - (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
Unit transporter-usually a van type vehicle or passenger car):or CO
L ---------- o y� 4. Is used or desi nated to trans rt between 9 and 15 passengers, ng C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L i.till 1 . . i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). m
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CARRIER NAME welch bros Inc Z
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Not To Scale ADDRESS 1050 ST CHARLES ST D
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CITY/STATE/ZIP E LG I N 1 IL/60120 o
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MOTOR CARR.ID 0 Interstate El Intrastate
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other
i'----Y----1 - USDOT NO. 492714 ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash? A
❑ Yes I 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 ®No 2
TRAILER VIN 1 1 M2AA13Y8WW082134 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ M Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 20 ft. 2 ft. w
Black Red
u 1 TOWED TOTAL VEHICLE LENGTH 35 F ft. NO.OF AXLES 5
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
_Arties . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE LOAD TYPE