20190518 sova19051822
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0002 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
07:11 PM
Date Notified
05/18/2019
Time Arrived
07:42 PM
Date Arrived
05/18/2019
Crash Time
99:99
Crash Date
05/18/2019
Investigating Officer/Deputy
DEPUTY MATTHEW JEFSON
Agency Crash NumberPrimary Crash Document #Document Number Override
6VL0FB0002Additional InformationPHOTOS
Photos ByM. 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 OF THE SAWYER COUNTY SHERIFF'S DEPARTMENT WAS DISPATCHED TO THE WANNIGANS BAR IN THE OJIBWA
TOWNSHIP FOR A HIT AND RUN ACCIDENT IN THE PARKING LOT. I ARRIVED ON SCENE AND WAS MET BY MS. WHO ADVISED THAT SHE CAME
OUT TO GET SOMETHING FROM HER VEHICLE AND NOTICED THAT SOMEONE HAD SIDE SWIPED IT. THERE WAS DAMAGE TO THE DRIVER DOOR
AND FRONT DRIVERS SIDE QUARTER PANEL. MS. SOVA GAVE ME HER INSURANCE CARD. I THEN TOOK PHOTOS OF THE DAMAGE. I ASKED AROUND
AND NOBODY SEEN ANYTHING AND MS. WAS UNSURE WHAT TIME IT HAD ACTUALLY OCCURED.
Crash Time 99:99
Crash Date 05/18/2019Wisconsin Motor Vehicle Crash
Form DT4000 1 of 5
This report does not include any CJIS data.
19051822
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0002 WISCONSIN MOTOR VEHICLE
CRASH REPORT
Structure Type
HOUSE/BUILDING
Y CoordinateX Coordinate
LongitudeLatitudePARKING LOT
CTHG NB LOT N5909
(HOUSE/BUILDING N5909)
IN THE TOWN OF OJIBWA
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
06--SIDESWIPE/OPPOSITE DIRECTION
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
UNKNOWN
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 FUNCTION
Most Harmful Event: Collision With
PARKED MOTOR VEHICLE
Total Lanes
0
Speed LimitPre CrashTire
Mark
Direction Of Travel
NOT ON ROADWAY
Insurance?
YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # RecordedTotal Occs
0
Operating As EndorsementsVehicle Type
PASSENGER VAN01 Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
LEGALLY PARKED
Unit Summary
UNITExtent Of Damage
FUNCTIONAL DAMAGE
Vehicle Damage
9--LEFT SIDE MIDDLE, 10--LEFT SIDE FRONT, 11--LEFT FRONT CORNER
Initial Contact Point
9--LEFT SIDE MIDDLE
Bus Use
NOT A BUS
Body Style
VN - VAN
Color
BLK - BLACK
Model
GRAND CARA
Year
2015
Make
DODGE
Vehicle Identification Number
83850101 Country of Issuance
UNITED STATES
St
WI
Plate Type
AUT - AUTOMOBILE
License Plate Number
Vehicle
UNITVEHICLECrash Time 99:99
Crash Date 05/18/2019Wisconsin Motor Vehicle Crash
Form DT4000 2 of 5
This report does not include any CJIS data.
19051822
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0002 WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
HAYWARD, WI 54843 , US
Owner Name
0101Driver Actions
NO CONTRIBUTING ACTION
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
LEGALLY PARKED
Vehicle Removed By
OPERATOR
Towed Due To Damage
NOT TOWED
VEHICLEUNIT Sequence Of Events
Event
PARKED MOTOR VEHICLE01
Event
02Event
03Event
04IndividualInsurance Company
STATE-FARM-MUTUAL-AUTOMOBILE-INS-CO
Policy Holder
UNITTruck Bus or HazMat
NO
Road Grade
UNKNOWN
Road Curvature
UNKNOWN
Surface Type
UNKNOWN
Traffic Control Inoperative/Missing
UNKNOWN
Traffic Control
UNKNOWN
Traffic Way
UNKNOWN
Emergency Motor Vehicle Use
UNKNOWN
Special Function
UNKNOWN
Most Harmful Event: Collision With
PARKED MOTOR VEHICLE
Total Lanes
0
Speed LimitPre CrashTire
Mark
Direction Of Travel
UNKNOWN
Insurance?
UNKNOWN
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # RecordedTotal Occs
1
Operating As EndorsementsVehicle Type
PASSENGER CAR02 Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
HIT AND RUN
Unit Summary
UNITExtent Of Damage
VEHICLE NOT AT SCENE
Vehicle Damage
VEHICLE NOT AT SCENE
Initial Contact Point
VEHICLE NOT AT SCENE
Bus Use
NOT A BUS
Body StyleColor
ModelYearMakeVehicle Identification Number
0202Country of IssuanceStPlate TypeLicense Plate Number
Vehicle
UNITVEHICLECrash Time 99:99
Crash Date 05/18/2019Wisconsin Motor Vehicle Crash
Form DT4000 3 of 5
This report does not include any CJIS data.
19051822
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0002 WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
, ,
Owner Name
0202Driver Actions
UNKNOWN
Driver Prior Action Other
Vehicle Factors
UNKNOWN
What Driver Was Doing
UNKNOWN
Vehicle Removed By
OPERATOR
Towed Due To Damage
NOT TOWED
VEHICLEUNIT Sequence Of Events
Event
PARKED MOTOR VEHICLE01
Event
02Event
03Event
04Injury
Distracted By
LocationStriking Unit #
Distracted By Action
Distracted By Source
Time of DeathDate of DeathHospital
EMS Run #EMS Agency IdentifierMedical Transport
NOT TRANSPORTED
Trapped/Extricated
NOT APPLICABLE
Ejection Path
NOT EJECTED/NOT APPLICABLE
Ejected
NOT APPLICABLE
Airbag
NOT APPLICABLE
Injury Severity
NO APPARENT INJURY00102 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 NumberAddress
, ,
RaceDate of Birth
SexCitations Issued
0
Driver
UN Individual
Non Motorist
Safety EquipmentITIDUALINDIV
Crash Time 99:99
Crash Date 05/18/2019Wisconsin Motor Vehicle Crash
Form DT4000 4 of 5
This report does not include any CJIS data.
19051822
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0002 WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
NOT OBSERVED
Drug Type
00102Drug Test ResultsDrug Test TypeDrug Test Given
TEST NOT GIVEN
Alcohol Test ResultsAlcohol Test TypeAlcohol Test Given
TEST NOT GIVEN
Suspected Drug UseSuspected Alcohol Use
To/From SchoolAction Other
Action
Prior Action
UNITINDIVIDUALCrash Time 99:99
Crash Date 05/18/2019Wisconsin Motor Vehicle Crash
Form DT4000 5 of 5
This report does not include any CJIS data.