20190604 hollen - headleyON JUNE 4, 2019, I, DEPUTY AMBER AL-MOGHRABI, WAS WORKING PATROL FOR THE SAWYER COUNTY SHERIFF'S DEPARTMENT. AT
APPROXIMATELY 15:21 DISPATCHED ADVISED DEPUTY JENSEN TO RESPOND TO THE LCO COUNTRY STORE AT 8575 COUNTY ROAD K, FOR A TWO
VEHICLE ACCIDENT WITH NO INJURIES. I ADVISED DISPATCH THAT I WAS JUST DOWN THE ROAD AND WOULD RESPOND TO THE ACCIDENT. UPON
ARRIVAL AT 15:24 I NOTICED A WHITE DODGE RAM, WHO I HAD KNOWN BELONGED TO AND A KIA SORENTO WITH A
MINNESOTA PLATE SITTING NEXT TO EACH OTHER IN THE PARKING LOT. I GOT OUT OF MY PATROL VEHICLE AND WENT TO TALK TO
AND THE FEMALE THAT WAS DRIVING THE KIA. STATED THAT HE WAS SITTING IN HIS TRUCK PARKED IN HIS
PARKING SPOT WHEN HE NOTICED A VEHICLE BACKING OUT OF THE PARKING STALL IN FRONT OF HIM. HE STATED THAT HE NOTICED HER
TURNING TO WIDE AND SAW THAT SHE WAS ABOUT TO HIT HIS TRUCK SO HE STARTED HONKING THE HORN TO GET HER ATTENTION.
STATED THAT THE FEMALE DRIVER MUST NOT HAVE HEARD HIM AND HER REAR END HIT THE PASSENGER SIDE OF THE FRONT
END OF HIS TRUCK. I ASKED THE FEMALE IF THAT IS WHAT HAD HAPPENED AND SHE STATED IT WAS AND THAT SHE DID NOT SEE HIM WHEN SHE
WAS BACKING UP.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF 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
03:22 PM
Date Notified
06/04/2019
Time Arrived
03:24 PM
Date Arrived
06/04/2019
Crash Time
03:15 PM
Crash Date
06/04/2019
Investigating Officer/Deputy
DEPUTY AMBER ALMOGHRABI
Agency Crash Number
19060413
Primary Crash Document #Document Number Override
6VL0FZQKRFAdditional InformationPHOTOS
Photos ByDEPUTY AMBER AL-MOGHRABI
Reconstruction ByDiagram
Description
I, a sworn law enforcement officer, agree that I have not added any CJIS data in this report.
Crash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 1 of 8
This report does not include any CJIS data.
I RAN THE MINNESOTA PLATE - THROUGH DISPATCH WHICH CAME BACK TO I ASKED THE FEMALE IF SHE WAS
AND SHE STATED SHE WAS. I THEN ADVISED DISPATCH TO RUN ROBIN AS SHE WAS THE DRIVER OF THE KIA. I THEN RAN THE WI LICENSE PLATE
ON THE DODGE RAM WHICH CAME BACK TO I ASKED DISPATCH TO ALSO RUN HIM AS HE WAS THE DRIVER OF THE
OTHER VEHICLE. I ASKED IF HE HAD BEEN WEARING HIS SEATBELT AND HE STATED HE WAS AND THAT HE WAS THE ONLY PERSON
IN HIS VEHICLE. ALSO STATED THAT HE HAD STATE FARM FOR INSURANCE. I THEN ASKED IF SHE WAS WEARING HER
SEATBELT. SHE STATED SHE WAS AND THAT WAS IN THE PASSENGER SEAT AND WAS ALSO WEARING HIS SEATBELT. SEE REPORT FOR
MORE.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Structure Type
NO STRUCTURE
Y CoordinateX Coordinate
LongitudeLatitudePARKING LOT
COUNTY ROAD K LOT
IN THE TOWN OF BASS LAKE
IN SAWYER COUNTY
Location
Special StudyAccess Control
NO CONTROL
Tribal Land
Crash Classification - Jurisdiction
NO SPECIAL JURISDICTION
Crash Classification - Location
PUBLIC PROPERTY
Relation To Trafficway
NON TRAFFICWAY - PARKING LOT
Animal Type
Weather Condition(s)
CLEAR
Environment Factor(s)
NONE
Roadway Factor(s)
NONE
Road Surface Condition(s)
DRY
Light Condition
DAYLIGHT
Manner of Collision
02--FRONT TO REAR
First Harmful Event Location
IN PARKING LANE OR ZONE
First Harmful Event
PARKED MOTOR VEHICLE
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
BLACKTOP (BITUMINOUS)
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 FUNCTION
Most Harmful Event: Collision With
PARKED MOTOR VEHICLE
Total Lanes
0
Speed Limit
05
Pre CrashTire
Mark
Direction Of Travel
NOT ON ROADWAY
Insurance?
YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # InjuredTotal Occs
3
Operating As EndorsementsVehicle Type
(SPORT) UTILITY VEHICLE01 Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
IN TRANSIT
Unit Summary
UNITModel
SORENTO
Year
2019
Make
KIA MOTORS CORPORA
Vehicle Identification Number
041480101 Country of Issuance
UNITED STATES
St
MN
Plate Type
AUT - AUTOMOBILE
License Plate Number
Vehicle
Crash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 2 of 8
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner AddressOwner Name01Driver Distractions
UNKNOWN IF DISTRACTED
01Driver Actions
UNSAFE BACKING
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
BACKING
Vehicle Removed ByTowed Due To Damage
NOT TOWED
Extent Of Damage
MINOR DAMAGE
Vehicle Damage
6--REAR
Initial Contact Point
6--REAR
Bus Use
NOT A BUS
Body Style
UT - SPORT UTILITY VEHICLE
Color
WHI - WHITE
VEHICLEUNITUNITVEHICLE Sequence Of Events
Event
PARKED MOTOR VEHICLE01
Event
02Event
03Event
04Individual
ROBIN TAINTER
Insurance Company
ALLSTATE-INS-CO
Policy Holder
UNITHelmet 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
COUDERAY, WI 54828 , US
Race
INDIAN
Date of Birth
09/27/
Sex
FEMALE
Citations Issued
0
Driver
ITEquipment
Individual
UNINDIVIDUALCrash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 3 of 8
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Injury
Drug & Alcohol
Individual Condition
APPEARED NORMAL
Drug Type
00101Drug Test ResultsDrug Test TypeDrug Test Given
TEST 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
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICABL
Ejected
NOT EJECTED
Airbag
NON DEPLOYED
Injury Severity
NO APPARENT INJURY00101 Tint ComplianceEye Protection
UNIT Non Motorist
INDIVIDUALInjury
EMS Run #EMS Agency IdentifierMedical Transport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICABL
Ejected
NOT EJECTED
Airbag
NON DEPLOYED
Injury Severity
NO APPARENT INJURY00201 Tint ComplianceEye Protection
Helmet ComplianceHelmet Use
Seat Position
3--FRONT SEAT-RIGHT SIDE (TRAIN ENGINEER
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
04/25/1
Sex
MALE
Citations Issued
0
Passenger
ITEquipment
Individual
UNINDIVIDUALCrash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 4 of 8
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
APPEARED NORMAL
Drug Type
00201Drug Test ResultsDrug Test TypeDrug Test Given
TEST 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
UNIT Non Motorist
INDIVIDUALInjury
To/From SchoolLocationPrior ActionStriking Unit #
Time of DeathDate of DeathHospital
EMS Run #EMS Agency IdentifierMedical Transport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICABL
Ejected
NOT EJECTED
Airbag
NON DEPLOYED
Injury Severity
NO APPARENT INJURY00301 Tint ComplianceEye Protection
Helmet ComplianceHelmet Use
Seat Position
6--SECOND SEAT-RIGHT SIDE
Safety Equipment
CHILD RESTRAINT - TYPE UNKNOWN
On Duty Crash
Driver License NumberAddress
HAYWARD, WI 54843 , US
Race
INDIAN
Date of Birth
03/06/
Sex
FEMALE
Citations Issued
0
Passenger
ITEquipment
Non Motorist
Individual
UNINDIVIDUALCrash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 5 of 8
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
APPEARED NORMAL
Drug Type
00301Drug Test ResultsDrug Test TypeDrug Test Given
TEST NOT GIVEN
Alcohol Test ResultsAlcohol Test TypeAlcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
Action Other
Action
UNITINDIVIDUALTruck 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
PARKING LOT OR PRIVATE PROPERTY
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTION
Most Harmful Event: Collision With
PARKED MOTOR VEHICLE
Total Lanes
0
Speed Limit
05
Pre CrashTire
Mark
Direction Of Travel
NOT ON ROADWAY
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 TRUCK02 Unit Type
TRUCK
Vehicle Operating As Classification
D CLASS
Unit Status
LEGALLY PARKED
Unit Summary
UNITDriver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
LEGALLY PARKED
Vehicle Removed By
OWNER
Towed Due To Damage
NOT TOWED
Extent Of Damage
MINOR DAMAGE
Vehicle Damage
1--RIGHT FRONT CORNER
Initial Contact Point
1--RIGHT FRONT CORNER
Bus Use
NOT A BUS
Body Style
PK - PICKUP
Color
WHI - WHITE
Model
RAM 2500
Year
2009
Make
DODGE
Vehicle Identification Number
607670202 Country of Issuance
UNITED STATES
St
WI
Plate Type
FFO - FIRE FIGHTER RED
License Plate Number
VEHICLEUNIT Vehicle
Crash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 6 of 8
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
HAYWARD, WI 54843 , US
Owner Name02Driver Distractions
NOT DISTRACTED
02Driver Actions
NO CONTRIBUTING ACTION
UNITVEHICLE Sequence Of Events
Event
PARKED MOTOR VEHICLE01
Event
02Event
03Event
04IndividualInsurance Company
STATE-FARM-GENERAL-INS-CO
Policy Holder
UNITInjury
To/From SchoolLocationPrior ActionStriking Unit #
Time of DeathDate of DeathHospital
EMS Run #EMS Agency IdentifierMedical Transport
NOT TRANSPORTED
Trapped/Extricated
UNKNOWN
Ejection Path
UNKNOWN
Ejected
UNKNOWN
Airbag
UNKNOWN
Injury Severity
NO APPARENT INJURY00402 Tint ComplianceEye Protection
Helmet ComplianceHelmet Use
Seat Position
1--FRONT SEAT-LEFT SIDE (DRIVER/MOTORCY
Safety Equipment
NONE USED - VEHICLE OCCUPANT
On Duty Crash
Driver License Number
STATE: WISCONSIN COUNTRY: UNITED STATES
Address
HAYWARD, WI 54843 , US
Race
WHITE
Date of Birth
12/24/
Sex
MALE
Citations Issued
0
Unknown
ITEquipment
Non Motorist
Individual
UNINDIVIDUALCrash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 7 of 8
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FZQKRF WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
APPEARED NORMAL
Drug Type
00402Drug Test ResultsDrug Test TypeDrug Test Given
TEST NOT GIVEN
Alcohol Test ResultsAlcohol Test TypeAlcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
Action Other
Action
UNITINDIVIDUALCrash Time 03:15 PM
Crash Date 06/04/2019Wisconsin Motor Vehicle Crash
Form DT4000 8 of 8
This report does not include any CJIS data.