20190212 WHITE.pdf19021204
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL133SSFK 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
03:17 PM
Date Notified
02/12/2019
Time Arrived
03:34 PM
Date Arrived
02/12/2019
Crash Time
03:17 PM
Crash Date
02/12/2019
Investigating Officer/Deputy
DEPUTY SEAN ANDERSON
Agency Crash Number
19021204
Primary Crash Document #Document Number Override
6V
L
1
3
3
S
S
F
K
Additional InformationNONE
Photos By
Reconstruction ByDiagram
Description
I, a sworn law enforcement officer, agree that I have not added any CJIS data in this report.
UNIT1 WAS SNOWPLOWING DRIVEWAY TO 8530N COUNTY RD K. UNIT 1 WAS BACKING UP AND DID NOT SEE UNIT2. UNIT 2 WAS TRAVELING NORTH
ON COUNTY RD K. UNIT 1 BACKED INTO ROADWAY AND STRUCK UNIT 2 IN THE FRONT RIGHT CORNER. UNIT 2 WAS UNABLE TO STOP BECAUSE
OF SNOWY AND ICY ROADS. DRIVER OF UNIT 1 SAID HE LOOKED BUT DID NOT SEE UNIT 2.
Crash Time 03:17 PM
Crash Date 02/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 1 of 6
This report does not include any CJIS data.
19021204
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL133SSFK WISCONSIN MOTOR VEHICLE
CRASH REPORT
Structure Type
HOUSE/BUILDING
Y Coordinate
5096967.5
X Coordinate
160696.359375
Longitude
-91.377532871
Latitude
45.942363702
ON 8530N CTHK NB
71 FT N
OF CTHE NB
(HOUSE/BUILDING 8530N)
IN THE TOWN OF BASS LAKE
IN SAWYER COUNTY
Location
Special StudyAccess Control
NO 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)
SNOW
Environment Factor(s)
WEATHER CONDITIONS
Roadway Factor(s)
ROAD SURFACE CONDITION (WET, ICY, SNOW, SLUSH,
ETC)
Road Surface Condition(s)
SNOW
Light Condition
DAYLIGHT
Manner of Collision
02--FRONT TO REAR
First Harmful Event Location
ON ROADWAY
First Harmful Event
MOTOR VEH IN TRANSPORT
Crash Scene
Intersection Type
NOT AN INTERSECTION
Junction Location
NON-JUNCTION
Within Interchange Area
NO
Truck Bus or HazMat
NO
Road Grade
LEVEL
Road Curvature
STRAIGHT
Surface Type
SLAG, GRAVEL, OR STONE
Traffic Control Inoperative/Missing
NO
Traffic Control
NO CONTROL
Traffic Way
PARKING LOT OR PRIVATE PROPERTY
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTIONMost Harmful Event: Collision With
MOTOR VEH IN TRANSPORT
Total Lanes
1
Speed Limit
N/APre CrashTire
Mark
Direction Of Travel
WESTBOUND
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
MINOR DAMAGE
Vehicle Damage
6--REAR
Initial Contact Point
6--REAR
Bus UseNOT A BUSBody Style
PK - PICKUP
Color
MAR - MAROON (BURGUNDY)
Model
RAM
Year
2014
Make
DODGE
Vehicle Identification Number
24110101
Country of Issuance
UNITED STATES
St
WI
Plate Type
MUN - MUNICIPAL
License Plate Number
VE
H
I
C
L
E
UN
I
T
Vehicle
Crash Time 03:17 PM
Crash Date 02/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 2 of 6
This report does not include any CJIS data.
19021204
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL133SSFK WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
HAYWARD, WI 54843 , US
Owner Name
01
Driver DistractionsLOOKED BUT DID NOT SEE
01
Driver Actions
UNSAFE BACKING
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
BACKING
Vehicle Removed By
OPERATOR
Towed Due To Damage
NOT TOWED
UN
I
T
VE
H
I
C
L
E
Sequence Of Events
EventMOTOR VEH IN TRANSPORT01
Event
02
Event
03
Event
04
Government
LAC COURTE OREILLES TRIBE
Insurance Company
HUDSON-INS-CO
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
STONE LAKE, WI 54876 , US
Race
INDIAN
Date of Birth
09/27/
Sex
MALE
Citations Issued
0
Driver
IT
Equipment
Individual
UN
IN
D
I
V
ID
U
A
L
Crash Time 03:17 PM
Crash Date 02/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 3 of 6
This report does not include any CJIS data.
19021204
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL133SSFK 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
BLACKTOP (BITUMINOUS)
Traffic Control Inoperative/Missing
NO
Traffic Control
NO CONTROL
Traffic Way
TWO-WAY, NOT DIVIDED
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTIONMost Harmful Event: Collision With
MOTOR VEH IN TRANSPORT
Total Lanes
2
Speed Limit
35Pre CrashTire
Mark
Direction Of Travel
NORTHBOUND
Insurance?
YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # InjuredTotal Occs
1
Operating As EndorsementsVehicle Type
(SPORT) UTILITY VEHICLE02
Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
IN TRANSIT
Unit Summary
UN
IT
Extent Of Damage
FUNCTIONAL DAMAGE
Vehicle Damage
12--FRONT
Initial Contact Point
12--FRONT
Bus UseNOT A BUSBody Style
UT - SPORT UTILITY VEHICLE
Color
SIL - SILVER (ALUMINUM)
Model
LIBERTY
Year
2003
Make
JEEP
Vehicle Identification Number
91790202
Country of Issuance
UNITED STATES
St
WI
Plate Type
LCO - LAC COURTE OREI
License Plate Number
VE
H
I
C
L
E
UN
I
T
Vehicle
Crash Time 03:17 PM
Crash Date 02/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 4 of 6
This report does not include any CJIS data.
19021204
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL133SSFK WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
HAYWARD, WI 54843 , US
Owner Name
02
Driver DistractionsNOT DISTRACTED
02
Driver Actions
NO CONTRIBUTING ACTION
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
GOING STRAIGHT
Vehicle Removed By
OPERATOR
Towed Due To Damage
NOT TOWED
UN
I
T
VE
H
I
C
L
E
Sequence Of Events
EventMOTOR VEH IN TRANSPORT01
Event
02
Event
03
Event
04
IndividualInsurance Company
AIG-ASURANCE-CO
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
2
02
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
Race
INDIAN
Date of Birth
Sex
FEMALE
Citations Issued
0
Driver
IT
Equipment
Individual
UN
IN
D
I
V
ID
U
A
L
Crash Time 03:17 PM
Crash Date 02/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 5 of 6
This report does not include any CJIS data.
19021204
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL133SSFK WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
APPEARED NORMAL
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 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
Crash Time 03:17 PM
Crash Date 02/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 6 of 6
This report does not include any CJIS data.