20190926 cave19092644
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0005 WISCONSIN MOTOR VEHICLE
CRASH REPORT
Secondary
CrashAmendedCrash Type
PRIVATE PROPERTY/PARKING LOTReportable
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
11:12 PM
Date Notified
09/26/2019
Time Arrived
11:45 PM
Date Arrived
09/26/2019
Crash Time
11:12 PM
Crash Date
09/26/2019
Investigating Officer/Deputy
DEPUTY MATTHEW JEFSON
Agency Crash NumberPrimary Crash Document #Document Number Override
6VL0FB0005Additional 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 RESPONDED TO A TWO VEHICLE CRASH AT THE PARKING LOT AT 9107N RIVER RD. I ARRIVED AND WAS MET BY THE OWNER OF UNIT 1. HE
ADVISED THAT UNIT 2 LEFT DUE TO THE TIME IT TOOK TO ARRIVE. UNIT 1 ADVISED THAT UNIT 2 LEFT ALL HIS INFORMATION. I GATHERED THAT
INFORMATION AND ALSO UNIT 1'S INFORMATION. UNIT 1 ADVISED THAT UNIT 2 WAS LEAVING AND BACKED INTO HIS VEHICLE WITH HIS HITCH. I
TOOK PHOTOGRAPHS AND CLEARED.
Crash Time 11:12 PM
Crash Date 09/26/2019Wisconsin Motor Vehicle Crash
Form DT4000 1 of 5
This report does not include any CJIS data.
19092644
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0005 WISCONSIN MOTOR VEHICLE
CRASH REPORT
Structure Type
HOUSE/BUILDING
Y CoordinateX Coordinate
LongitudeLatitudeINTERSECTION
ON 9107 RIVER RD
AT PARKING LOT
(HOUSE/BUILDING 9107)
IN THE TOWN OF HUNTER
IN SAWYER COUNTY
Location
Special StudyAccess Control
NO CONTROL
Tribal Land
Crash Classification - Jurisdiction
PRIVATE PROPERTY
Crash Classification - Location
PRIVATE 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
DARK/UNLIT
Manner of Collision
04--REAR 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 CurvatureSurface Type
BRICK OR BLOCK
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 LanesSpeed 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
(SPORT) UTILITY VEHICLE01 Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
LEGALLY PARKED
Unit Summary
UNITExtent Of Damage
FUNCTIONAL DAMAGE
Vehicle Damage
6--REAR
Initial Contact Point
6--REAR
Bus Use
NOT A BUS
Body Style
UT - SPORT UTILITY VEHICLE
Color
WHI - WHITE
Model
EXPLORER
Year
2017
Make
FORD
Vehicle Identification Number
95040101 Country of Issuance
UNITED STATES
St
WI
Plate Type
AUT - AUTOMOBILE
License Plate Number
Vehicle
UNITVEHICLECrash Time 11:12 PM
Crash Date 09/26/2019Wisconsin Motor Vehicle Crash
Form DT4000 2 of 5
This report does not include any CJIS data.
19092644
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0005 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
WISCONSIN-MUTUAL-INS-CO
Policy Holder
UNITTruck Bus or HazMat
NO
Road Grade
LEVEL
Road Curvature
UNKNOWN
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 LanesSpeed 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
1
Operating As EndorsementsVehicle Type
PASSENGER CAR02 Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
IN TRANSIT
Unit Summary
UNITExtent Of Damage
NO DAMAGE
Vehicle Damage
NO DAMAGE
Initial Contact Point
6--REAR
Bus Use
NOT A BUS
Body Style
PK - PICKUP
Color
GRY - GRAY
Model
F350
Year
2013
Make
FORD
Vehicle Identification Number
875310202 Country of Issuance
UNITED STATES
St
WI
Plate Type
AUT - AUTOMOBILE
License Plate Number
Vehicle
UNITVEHICLECrash Time 11:12 PM
Crash Date 09/26/2019Wisconsin Motor Vehicle Crash
Form DT4000 3 of 5
This report does not include any CJIS data.
19092644
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0005 WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
ROBERTS, WI 54023 , US
Owner Name
0202Driver Actions
NO CONTRIBUTING ACTION
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
BACKING
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-GENERAL-INS-CO
Policy Holder
UNITInjury
Distracted By
Distracted By Action
NOT DISTRACTED
Distracted By Source
NOT APPLICABLE (NOT DISTRACTED)
Time of DeathDate of DeathHospital
EMS Run #EMS Agency IdentifierMedical Transport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICABLE
Ejected
NOT EJECTED
Airbag
NON DEPLOYED
Injury Severity
NO APPARENT INJURY00102 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
ROBERTS, WI 54023 , US
Race
WHITE
Date of Birth
06/18/
Sex
MALE
Citations Issued
0
Driver
E
UN Individual
Safety EquipmentITIDUALINDIV
Crash Time 11:12 PM
Crash Date 09/26/2019Wisconsin Motor Vehicle Crash
Form DT4000 4 of 5
This report does not include any CJIS data.
19092644
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0FB0005 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 Use
NO
Suspected Alcohol Use
NO
To/From SchoolAction Other
Action
Prior Action
LocationStriking Unit #Non Motorist
UNITINDIVIDUALCrash Time 11:12 PM
Crash Date 09/26/2019Wisconsin Motor Vehicle Crash
Form DT4000 5 of 5
This report does not include any CJIS data.