20190110 SIMON-STEVENS.pdf19011006
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL151TJNF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Secondary
CrashAmendedCrash Type
DT4000 (STANDARD CRASH)Reportable
TagsSchool Bus Related
NOActive School ZoneGovernment
Property
Reporting
ThresholdTrailer or TowedWork ZoneLane ClosureHit and RunOn Emergency
Total Killed
00
Total Injured
00
Total Units
02
Time Notified
07:02 PM
Date Notified
01/10/2019
Time Arrived
07:08 PM
Date Arrived
01/10/2019
Crash Time
07:00 PM
Crash Date
01/10/2019
Investigating Officer/Deputy
DEPUTY MATTHEW JEFSON
Agency Crash NumberPrimary Crash Document #Document Number Override
6V
L
1
5
1
T
J
N
F
Additional InformationPHOTOS
Photos ByDEPUTY MATTHEW JEFSON
Reconstruction ByDiagram
Description
I, a sworn law enforcement officer, agree that I have not added any CJIS data in this report.
I DEPUTY MATTHEW JEFSON WAS DISPATCHED TO A HIT AND RUN VEHICLE ACCIDENT ON CTH K NEAR GARY AVE. I ARRIVED ON SCENE AND MET
WITH THE DRIVER OF UNIT 1. I GATHERED HER INFORMATION AND TOOK PHOTOS OF THE DAMAGE. I ALSO GATHERED UP PARTS FROM UNIT 2
THAT WERE LEFT ON SCENE. I ASKED WHAT HAD TAKEN PLACE AND THE DRIVER OF UNIT 1 SAID THAT SHE WAS TRAVELING EASTBOUND ON CTH K WHEN SHE NOTICED A VEHICLE TRAVELING NORTHBOUND ON ADKINS ROAD. SHE SAID THAT IT LOOKED LIKE THE VEHICLE WASNT GOING TO
STOP SO SHE SWERVED INTO THE OPPOSITE LANE TO AVOID A COLLISION BUT UNIT 2 STRUCK HER IN THE REAR PASSENGER SIDE OF HER
TRUCK. SHE SAID THE VEHICLE THEN JUST KEPT ON DRIVING. A SHORT TIME LATER THE DRIVER OF UNIT 2 CALLED DISPATCH AND ADVISED
WHERE HE WAS. I WENT TO HIS LOCATION AND TOOK PHOTOS OF THE DAMAGE TO HIS VEHICLE. I ASKED WHAT HAD HAPPENED AND HE SAID HE
TRIED TO STOP AT THE SIGN BUT DUE TO ICE ON THE ROADS WAS UNABLE TO STOP. HE THEN SAID HE GOT NERVOUS AND DIDNT HAVE A PHONE
TO CALL LAW ENFORCEMENT SO HE CAME HOME AND CALLED.
Crash Time 07:00 PM
Crash Date 01/10/2019Wisconsin Motor Vehicle Crash
Form DT4000 1 of 6
This report does not include any CJIS data.
19011006
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL151TJNF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Structure Type
Y Coordinate
5093931.5
X Coordinate
158428.25
Longitude
-91.404546517
Latitude
45.913994942
INTERSECTION
ON CTHK EB
AT ATKINS AVE
IN THE TOWN OF BASS LAKE
IN SAWYER COUNTY
Location
Special StudyAccess Control
FULL CONTROL
Tribal Land
LAC COURTE OREILLES BAND
Crash Classification - Jurisdiction
INDIAN RESERVATION/TRUST
Crash Classification - Location
TRIBAL LAND
Relation To Trafficway
TRAFFICWAY - ON ROAD
Animal Type
Weather Condition(s)
CLEAR
Environment Factor(s)
NONE
Roadway Factor(s)
NONE
Road Surface Condition(s)
ICE
Light Condition
DARK/LIGHTED
Manner of Collision
08--FRONT TO SIDE
First Harmful Event Location
ON ROADWAY
First Harmful Event
MOTOR VEH IN TRANSPORT
Crash Scene
Intersection Type
T-INTERSECTION
Junction Location
INTERSECTION
Within Interchange Area
NO
Truck Bus or HazMat
NO
Road Grade
LEVEL
Road Curvature
STRAIGHT
Surface Type
BLACKTOP (BITUMINOUS)
Traffic Control Inoperative/Missing
NO
Traffic Control
NO CONTROL
Traffic Way
DIVIDED HWY W/O TRAFFIC BARRIER
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTIONMost Harmful Event: Collision With
MOTOR VEH TRAN OTHER RDWY
Total Lanes
2
Speed Limit
35Pre CrashTire
Mark
Direction Of Travel
EASTBOUND
Insurance?
YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # InjuredTotal Occs
1
Operating As EndorsementsVehicle Type
UTILITY TRUCK/PICKUP TRUCK01
Unit Type
TRUCK
Vehicle Operating As Classification
D CLASS
Unit Status
IN TRANSIT
Unit Summary
UN
IT
Extent Of Damage
FUNCTIONAL DAMAGE
Vehicle Damage
4--RIGHT SIDE REAR, 5--RIGHT REAR CORNER, 6--REAR
Initial Contact Point
5--RIGHT REAR CORNER
Bus UseNOT A BUSBody Style
PK - PICKUP
Color
SIL - SILVER (ALUMINUM)
Model
SILVERADO
Year
2012
Make
CHEVROLET
Vehicle Identification Number
24860101
Country of Issuance
UNITED STATES
St
WI
Plate Type
FFO - FIRE FIGHTER RED
License Plate Number
VE
H
I
C
L
E
UN
I
T
Vehicle
Crash Time 07:00 PM
Crash Date 01/10/2019Wisconsin Motor Vehicle Crash
Form DT4000 2 of 6
This report does not include any CJIS data.
19011006
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL151TJNF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
HAYWARD, WI 54843 , US
Owner Name
01
Driver DistractionsNOT DISTRACTED
01
Driver Actions
NO CONTRIBUTING ACTION
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
GOING STRAIGHT
Vehicle Removed By
OWNER
Towed Due To Damage
NOT TOWED
UN
I
T
VE
H
I
C
L
E
Sequence Of Events
EventMOTOR VEH IN TRANSPORT01
EventMOTOR VEH TRAN OTHER RDWY02
Event
03
Event
04
IndividualInsurance Company
ESURANCE-INSURANCE-COMPANY
Policy Holder
UN
I
T
Injury
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICABL
Ejected
NOT EJECTED
Airbag
NON DEPLOYED
Injury Severity
NO APPARENT INJURY00
1
01
Tint ComplianceEye Protection
Helmet ComplianceHelmet Use
Seat Position
1--FRONT SEAT-LEFT SIDE (DRIVER/MOTORCY
Safety Equipment
SHOULDER & LAP BELT
On Duty Crash
Driver License Number
STATE: WISCONSIN COUNTRY: UNITED STATES
Address
HAYWARD, WI 54843 , US
RaceDate of Birth
10/12/
Sex
FEMALE
Citations Issued
0
Driver
IT
Equipment
Individual
UN
IN
D
I
V
ID
U
A
L
Crash Time 07:00 PM
Crash Date 01/10/2019Wisconsin Motor Vehicle Crash
Form DT4000 3 of 6
This report does not include any CJIS data.
19011006
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL151TJNF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
APPEARED NORMAL
Drug Type
00
1
01
Drug Test ResultsDrug Test TypeDrug Test GivenTEST NOT GIVEN
Alcohol Test ResultsAlcohol Test TypeAlcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
Action Other
Action
To/From SchoolLocationPrior ActionStriking Unit #
Time of DeathDate of DeathHospital
EMS Run #EMS Agency IdentifierMedical Transport
NOT TRANSPORTED
UN
I
T
Non Motorist
IN
D
I
V
I
D
U
A
L
Truck Bus or HazMat
NO
Road Grade
LEVEL
Road Curvature
STRAIGHT
Surface Type
DIRT
Traffic Control Inoperative/Missing
NO
Traffic Control
STOP SIGN
Traffic Way
TWO-WAY, NOT DIVIDED
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTIONMost Harmful Event: Collision With
MOTOR VEH TRAN OTHER RDWY
Total Lanes
2
Speed Limit
25Pre CrashTire
Mark
Direction Of Travel
NORTHBOUND
Insurance?
NO
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
3
Train/Bus # InjuredTotal Occs
1
Operating As EndorsementsVehicle Type
(SPORT) UTILITY VEHICLE02
Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
HIT AND RUN
Unit Summary
UN
IT
Extent Of Damage
FUNCTIONAL DAMAGE
Vehicle Damage
11--LEFT FRONT CORNER, 12--FRONT
Initial Contact Point
1--RIGHT FRONT CORNER
Bus UseNOT A BUSBody Style
UT - SPORT UTILITY VEHICLE
Color
SIL - SILVER (ALUMINUM)
Model
DURANGO
Year
2004
Make
DODGE
Vehicle Identification Number
47740202
Country of Issuance
UNITED STATES
St
WI
Plate Type
AUT - AUTOMOBILE
License Plate Number
VE
H
I
C
L
E
UN
I
T
Vehicle
Crash Time 07:00 PM
Crash Date 01/10/2019Wisconsin Motor Vehicle Crash
Form DT4000 4 of 6
This report does not include any CJIS data.
19011006
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL151TJNF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
HAYWARD, WI 54843 , US
Owner Name
02
Driver DistractionsNOT DISTRACTED
02
Driver Actions
SPEED TOO FAST/COND, UNKNOWN
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
SLOW/STOPPING
Vehicle Removed By
OPERATOR
Towed Due To Damage
NOT TOWED
UN
I
T
VE
H
I
C
L
E
Sequence Of Events
EventMOTOR VEH TRAN OTHER RDWY01
Event
02
Event
03
Event
04
Injury
EMS Run #EMS Agency IdentifierMedical Transport
NOT TRANSPORTED
Trapped/Extricated
NOT APPLICABLE
Ejection Path
NOT EJECTED/NOT APPLICABL
Ejected
NOT APPLICABLE
Airbag
NOT APPLICABLE
Injury Severity
NO APPARENT INJURY00
2
02
Tint ComplianceEye Protection
Helmet ComplianceHelmet Use
Seat Position
1--FRONT SEAT-LEFT SIDE (DRIVER/MOTORCY
Safety Equipment
RESTRAINT USE UNKNOWN
On Duty Crash
Driver License Number
STATE: WISCONSIN COUNTRY: UNITED STATES
Address
HAYWARD, WI 54843 , US
Race
INDIANDate of Birth
02/20/
Sex
MALE
Citations Issued
3
Driver
IT
Equipment
Individual
UN
IN
D
I
V
ID
U
A
L
Crash Time 07:00 PM
Crash Date 01/10/2019Wisconsin Motor Vehicle Crash
Form DT4000 5 of 6
This report does not include any CJIS data.
19011006
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL151TJNF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
NOT OBSERVED
Drug Type
00
2
02
Drug Test ResultsDrug Test TypeDrug Test GivenTEST NOT GIVEN
Alcohol Test ResultsAlcohol Test TypeAlcohol Test Given
TEST NOT GIVEN
Suspected Drug UseSuspected Alcohol Use
Action Other
Action
To/From SchoolLocationPrior ActionStriking Unit #
Time of DeathDate of DeathHospital
UN
I
T
Non Motorist
IN
D
I
V
I
D
U
A
L
Violations
DescriptionOPERATE MOTOR VEHICLE W/O INSURANCESeq Num001Statute Number344.62(1)Issue To?
002
UTC Number
BB32931601
DescriptionDRIVING TOO FAST FOR CONDITIONSSeq Num001Statute Number346.57(3)Issue To?
002
UTC Number
BB32931702
DescriptionHIT AND RUNSeq Num004Statute Number346.67(1)Issue To?
002
UTC Number
BB32931803
Crash Time 07:00 PM
Crash Date 01/10/2019Wisconsin Motor Vehicle Crash
Form DT4000 6 of 6
This report does not include any CJIS data.