HomeMy WebLinkAbout2026-00058094 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X092999
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ElOVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00058094 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 09 24 2026 ®AM ❑YES ®NO U1
S RANDALL RD Elgin 10:15
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD El STOPPED U2 —I
COAT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 ORNER ❑ PARKED ❑DRNERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 C)
FOR DAMAGED AREA(S) FRONT TOWED U1
McCullou h. Monica. L. 0 5 /
yr 13-UNDER CARRIAGE 10l �. 2 FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 99 f11
F 2 6 SY❑Y ®N SE❑UNK VEH. AT CRASH 99-UNKNOWN 9 76•TOP® `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s• iI 6 II COM VEH 0 E! 1 C)
F. FIRST CONTACT 4 7 _L--:;_OS •lives.See Sidebar U1 0
Z ELGIN IL 60124 0 1 0 A629575 IL 2027 REAR
TELEPHONE
IL D 0 JTHBJ46G582265156 Progressive ❑Y IlN U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Ubelhart. Mark.C. 968728678 1 11—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES ❑row 0 Ncv ❑Dv CIRCLE NUMBER(S) U1
/1 9 6 7 Nissan Rogue 2019 00-NONE ,i_"I Qi O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10) I 2 FIRE 0 ® U2 C
F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6-TOP 3 X
❑Y NJ El UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 I, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _6 •)ryes.See Sidebar
H ELGIN IL 60123 0 1 0 DIS818 IL 2027REAR
C
M
IL D 0 JN8AT2MV9KW398455 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 002836788 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 08 /
/ .../ 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 09/24 /2026 10 16 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 0 2 99 09/24 /2026 10 16 ❑PM El Construction
<w O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ®AM ❑Maintenance U2
o ® 11 4 ARREST NAME McCullough. Monica. L. 11-902 495000520 09/24/2026 10 21 ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM u, 55
T 2 0 ARREST NAME 09/24 /2026 11 10 I PM 0 Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 55
495-Sjodir.Jacob 702 275-Engelke 10 /20/2026 01 30 ®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 -<
` ` ' ' tillr INDICATE NORTH combination)or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I } (example:shuttle or charter bus):or
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3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
}-----I-•--; I wan I transportingemployees g employment(example:employee
} r } transporter-usuallyvan the cvehicle or pa se
1 1 1 _ y � type passenger car):or CO
' . 4. Is used or designated to transport between 9 and 15 passengers,including rCjt
< <.___a____� � } } } g Po passen rs,indudi the driver,
r for direct compensation(example:large van used for specific purpose):or
L - - A"" - - - - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires ill
r m
4l placarding(example:placards will be displayed on the vehicle).
WWI
j CARRIER NAME Z
ADDRESS
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CITY/STATEJZIP
- i. i. i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 1 T 1 Not To Scale I 0 Not in Comm./Govt. Not in Comm./Other
0 0
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
). 0 Yes 0 No ❑ Unknown A
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
71
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE