20191202 nugent- pedersonSAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0JB3P3K 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
02
Total Units
02
Time Notified
04:14 PM
Date Notified
12/02/2019
Time Arrived
04:15 PM
Date Arrived
12/02/2019
Crash Time
04:13 PM
Crash Date
12/02/2019
Investigating Officer/Deputy
DEPUTY NATHAN FREY
Agency Crash NumberPrimary Crash Document #Document Number Override
6VL0JB3P3KAdditional InformationNONE, PHOTOS
Photos By397
Reconstruction ByDiagram
Description
I, a sworn law enforcement officer, agree that I have not added any CJIS data in this report.
UNIT 1 WAS EXITING THE MARATHON GAS STATION. WHILE EXITING, UNIT 1 WAS HAVING DIFFICULTY GETTING TRACTION. UNIT 3 WAS
NORTHBOUND ON HIGHWAY 63 AFTER TURNING RIGHT OFF OF SOUTH KANSAS AVE. THE OPERATOR OF UNIT 3 NOTICED A PASSENGER CAR
TRAVELING NORTH IN THE INSIDE NORTH-BOUND LANE OF HIGHWAY 63. UNIT 3 ALSO OBSERVED UNIT 1 EXITING THE MARATHON GAS STATION
AND BEGAN TO SLOW. UNIT 2 OVERTOOK UNIT 3 AND STRUCK THE REAR DRIVER'S SIDE OF UNIT 1. BOTH UNIT 1 AND 2 ENDED UP IN THE
SOUTHBOUND OUTSIDE LANE. THE OPERATOR OF UNIT ONE APPEARED UNINJURED AND NO AIRBAGS WERE DEPLOYED. THE OPERATOR AND
PASSENGER OF UNIT 2 WERE SEEN AND TRANSPORTED BY SAWYER COUNTY EMT. UNIT 2 HAD A COMBINATION OF ALL FRONT AIRBAGS DEPLOY.
BOTH UNIT 1 AND 2 WERE REMOVED BY ROADRUNNER TOWING.
Crash Time 04:13 PM
Crash Date 12/02/2019Wisconsin Motor Vehicle Crash
Form DT4000 1 of 7
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0JB3P3K WISCONSIN MOTOR VEHICLE
CRASH REPORT
Structure Type
Y Coordinate
5105459
X Coordinate
153061.953125
Longitude
-91.481882914
Latitude
46.014746791
ON USH63 NB
179 FT W
OF CALIFORNIA AVE
IN THE CITY OF HAYWARD
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
TRAFFICWAY - ON ROAD
Animal Type
Weather Condition(s)
CLEAR
Environment Factor(s)
NONE
Roadway Factor(s)
NOT APPLICABLE
Road Surface Condition(s)
SNOW
Light Condition
DUSK
Manner of Collision
08--FRONT TO SIDE
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
BLACKTOP (BITUMINOUS)
Traffic Control Inoperative/Missing
NO
Traffic Control
NO CONTROL
Traffic Way
DIVIDED HWY W/O TRAFFIC BARRIER
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTION
Most Harmful Event: Collision With
MOTOR VEH IN TRANSPORT
Total Lanes
4
Speed Limit
25
Pre CrashTire
Mark
Direction Of Travel
WESTBOUND
Insurance?
YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # RecordedTotal Occs
1
Operating As EndorsementsVehicle Type
(SPORT) UTILITY VEHICLE01 Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
IN TRANSIT
Unit Summary
UNITExtent Of Damage
DISABLING DAMAGE
Vehicle Damage
8--LEFT SIDE REAR
Initial Contact Point
8--LEFT SIDE REAR
Bus Use
NOT A BUS
Body Style
UT - SPORT UTILITY VEHICLE
Color
GRY - GRAY
Model
CHEROKEE
Year
2016
Make
JEEP
Vehicle Identification Number
54750101 Country of Issuance
UNITED STATES
St
WI
Plate Type
AUT - AUTOMOBILE
License Plate Number
Vehicle
UNITVEHICLECrash Time 04:13 PM
Crash Date 12/02/2019Wisconsin Motor Vehicle Crash
Form DT4000 2 of 7
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0JB3P3K WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
N6628 METCALF RD
STONE LAKE, WI 54876 , US
Owner Name
TERI LYNN NUGENT
0101Driver Actions
NO CONTRIBUTING ACTION
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
ENTERING TRAFFIC LANE
Vehicle Removed ByTowed Due To Damage
TOWED DUE TO DISABLING DAMAGE
VEHICLEUNIT Sequence Of Events
Event
MOTOR VEH IN TRANSPORT01
Event
02Event
03Event
04Individual
Insurance Company
USAA-CASUALTY-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 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
STONE LAKE, WI 54876 , US
Race
WHITE
Date of Birth
06/12/
Sex
FEMALE
Citations Issued
0
Driver
UN Individual
Safety EquipmentITIDUALINDIV
Crash Time 04:13 PM
Crash Date 12/02/2019Wisconsin Motor Vehicle Crash
Form DT4000 3 of 7
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0JB3P3K 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
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
DIVIDED HWY W/O TRAFFIC BARRIER
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTION
Most Harmful Event: Collision With
MOTOR VEH IN TRANSPORT
Total Lanes
4
Speed Limit
25
Pre CrashTire
Mark
Direction Of Travel
NORTHBOUND
Insurance?
YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # RecordedTotal Occs
2
Operating As EndorsementsVehicle Type
PASSENGER CAR02 Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit Status
IN TRANSIT
Unit Summary
UNITVehicle Removed ByTowed Due To Damage
TOWED DUE TO DISABLING DAMAGE
Extent Of Damage
DISABLING DAMAGE
Vehicle Damage
1--RIGHT FRONT CORNER, 12--FRONT
Initial Contact Point
12--FRONT
Bus Use
NOT A BUS
Body Style
SD - SEDAN
Color
BLK - BLACK
Model
FUSION
Year
2014
Make
FORD
Vehicle Identification Number
30270202 Country of Issuance
UNITED STATES
St
WI
Plate Type
AUT - AUTOMOBILE
License Plate Number
Vehicle
UNITVEHICLECrash Time 04:13 PM
Crash Date 12/02/2019Wisconsin Motor Vehicle Crash
Form DT4000 4 of 7
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0JB3P3K WISCONSIN MOTOR VEHICLE
CRASH REPORT
Owner Address
12118 N UPPER A RD
HAYWARD, WI 54843 , US
Owner Name
MICHELLE KATE PEDERSON
0202Driver Actions
NO CONTRIBUTING ACTION
Driver Prior Action Other
Vehicle Factors
NOT APPLICABLE
What Driver Was Doing
GOING STRAIGHT
VEHICLEUNIT Sequence Of Events
Event
MOTOR VEH IN TRANSPORT01
Event
02Event
03Event
04Individual
Insurance Company
STATE-FARM-GENERAL-INS-CO
Policy Holder
UNITInjury
Distracted By
LocationStriking Unit #
Distracted By Action
NOT DISTRACTED
Distracted By Source
NOT APPLICABLE (NOT DISTRACTED)
Time of DeathDate of DeathHospital
HAYWARD AREA MEM HOSP
EMS Run #
1913795
EMS Agency Identifier
6000954
Medical Transport
EMS GROUND
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICABLE
Ejected
NOT EJECTED
Airbag
DEPLOYED-COMBINATION
Injury Severity
SUSPECTED MINOR INJURY00202 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
WHITE
Date of Birth
01/22/
Sex
FEMALE
Citations Issued
0
Driver
UN Individual
Non Motorist
Safety EquipmentITIDUALINDIV
Crash Time 04:13 PM
Crash Date 12/02/2019Wisconsin Motor Vehicle Crash
Form DT4000 5 of 7
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0JB3P3K WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
APPEARED NORMAL
Drug Type
00202Drug 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
UNITINDIVIDUALInjury
Distracted By
LocationStriking Unit #
Distracted By Action
Distracted By Source
Time of DeathDate of DeathHospital
HAYWARD AREA MEM HOSP
EMS Run #
1913795
EMS Agency Identifier
6000954
Medical Transport
EMS GROUND
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICABLE
Ejected
NOT EJECTED
Airbag
DEPLOYED-COMBINATION
Injury Severity
POSSIBLE INJURY00302 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 NumberAddress
HAYWARD, WI 54843 , US
RaceDate of Birth
06/21/
SexCitations Issued
0
Passenger
UN Individual
Non Motorist
Safety EquipmentITIDUALINDIV
Crash Time 04:13 PM
Crash Date 12/02/2019Wisconsin Motor Vehicle Crash
Form DT4000 6 of 7
This report does not include any CJIS data.
SAWYER COUNTY SHERIFFS DEPT
15880 EAST FIFTH STREET
HAYWARD, WI 54843
(715) 634-4858
6VL0JB3P3K WISCONSIN MOTOR VEHICLE
CRASH REPORT
Drug & Alcohol
Individual Condition
APPEARED NORMAL
Drug Type
00302Drug 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
UNITINDIVIDUALDate of Birth
04/21/
Address
HAYWARD, WI 54843 , US
Individual
(01Witness
WITNESSCrash Time 04:13 PM
Crash Date 12/02/2019Wisconsin Motor Vehicle Crash
Form DT4000 7 of 7
This report does not include any CJIS data.