20190912 statz19091240
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0GMH5JP 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
01
Time Notified
05:18 PM
Date Notified
09/12/2019
Time Arrived
05:25 PM
Date Arrived
09/12/2019
Crash Time
05:17 PM
Crash Date
09/12/2019
Investigating Officer/Deputy
DEPUTY AMANDA REED
Agency Crash NumberPrimary Crash Document #Document Number Override
6VL0GMH5JPAdditional InformationNONE
Photos ByDEPUTY AMANDA REED
Reconstruction ByDiagram
Description
I, a sworn law enforcement officer, agree that I have not added any CJIS data in this report.
ON SEPTEMBER 12TH, 2019, I, DEPUTY REED RESPONDED TO A ONE VEHICLE ACCIDENT IN WHICH THE DRIVER, , HAD STRUCK A POLE
IN THE PARKING LOT OF WALMART. THERE WAS NO DAMAGE TO THE POLE BUT EXTENSIVE DAMAGE TO HIS VEHICLE.
Crash Time 05:17 PM
Crash Date 09/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 1 of 4
This report does not include any CJIS data.
19091240
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0GMH5JP WISCONSIN MOTOR VEHICLE
CRASH REPORT
Structure Type
HOUSE/BUILDING
Y CoordinateX Coordinate
LongitudeLatitudePARKING LOT
STH77 WB LOT 15594
(HOUSE/BUILDING 15594)
IN THE CITY OF HAYWARD
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
DAYLIGHT
Manner of Collision
NO COLLISION W/VEHICLE IN TRANSPORT
First Harmful Event Location
IN PARKING LANE OR ZONE
First Harmful Event
OTHER POST, POLE OR SUPPORT
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
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
OTHER POST, POLE OR SUPPORT
Total Lanes
0
Speed Limit
N/A
Pre 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
UTILITY TRUCK/PICKUP TRUCK01 Unit Type
TRUCK
Vehicle Operating As Classification
D CLASS
Unit Status
IN TRANSIT
Unit Summary
UNITExtent Of Damage
DISABLING DAMAGE
Vehicle Damage
10--LEFT SIDE FRONT, 11--LEFT FRONT CORNER, 12--FRONT
Initial Contact Point
11--LEFT FRONT CORNER
Bus Use
NOT A BUS
Body Style
4D - 4DR
Color
BLK - BLACK
Model
SILVERADO
Year
2014
Make
CHEVROLET
Vehicle Identification Number
65440101 Country of Issuance
UNITED STATES
St
WI
Plate Type
LTK - LIGHT TRUCK
License Plate Number
Vehicle
UNITVEHICLECrash Time 05:17 PM
Crash Date 09/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 2 of 4
This report does not include any CJIS data.
19091240
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0GMH5JP WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
WISCONSIN RAPIDS, WI 54494 , US
Owner Name
0101Driver Actions
NO CONTRIBUTING ACTION
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
LEFT TURN
Vehicle Removed ByTowed Due To Damage
TOWED DUE TO DISABLING DAMAGE
VEHICLEUNIT Sequence Of Events
Event
MOTOR VEH IN TRANSPORT01
Event
OTHER POST, POLE OR SUPPORT02
Event
03Event
04IndividualInsurance Company
BADGER-MUTUAL-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
DEPLOYED-FRONT
Injury Severity
NO APPARENT INJURY00101 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
WISCONSIN RAPIDS, WI 54494 , US
Race
WHITE
Date of Birth
11/18/
Sex
MALE
Citations Issued
0
Driver
UN Individual
Safety EquipmentITIDUALINDIV
Crash Time 05:17 PM
Crash Date 09/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 3 of 4
This report does not include any CJIS data.
19091240
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0GMH5JP WISCONSIN MOTOR VEHICLE
CRASH REPORT
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
To/From SchoolAction Other
Action
Prior Action
LocationStriking Unit #Non Motorist
UNITINDIVIDUALCrash Time 05:17 PM
Crash Date 09/12/2019Wisconsin Motor Vehicle Crash
Form DT4000 4 of 4
This report does not include any CJIS data.