20131220 Moeller MilesWisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
GZOROF6 Page 1 of 5
'<t 0 0 N N .... M
'*" w u ::::i 0 ll.
'*" 1-z w c u u
<(
z
0
i= ~ 0:::
0 LL z -...J
<(
0::: w z w C>
.....
0
z <(
ii: ..... (/) w c w a.. -0::: 0 .....
<(
0::: w a..
0
~ Reportable Accident I 0 On Emergency 0 Amended
I DOT Document Number
GZOROF6
I Document Override Number
Agency Accident Number Police Number
13122004
4-Accident Date 1 5 -Time of Accident (Military Time) 1 6 -Total Units 1 7 -Total Injured 18-Total Killed
12/20/2013 1649 02 00 00
2 -County I 3 -Municipality 11 -Accident Location
SAWYER-57 LEN ROOT-08, TOWN NON-INTERSECTION
14-On Hwy No. 114-On Street Name
063
114-Bu s/Frnt/Rmp 15 - Est. Dist I Ft/Mi 115 -Hwy. Dir
100 F SOUTH
16 -Fr/At Hwy No.l16-From/At Street Name
STONE RD
116 -Business/Frontage/Ramp
17 -Structure Type 117 -Structure Number 112 -Latitude I ~ 3 - Longitude
80 -First Harmful Event 1 93-Mann er of Collision
MOTOR VEHICLE IN TRANSPORT REAR-END
112 -Access Control 1113 -Road Curvature 1113 - Road Terrain I Surface Type
NO CONTROL STRAIGHT LEVEL/FLAT BLACKTOP (BITUMINOUS)-2
115 -Traffic Way
NOT-PHYSICALL Y-DIVIDED-(2-WAY TRAFFIC)
117 -Relation To Roadway
ON-ROADWAY
114-Light Condition 1116 -Road Surface Condition 111 8 -Weather
DARK-NOT-LIGHTED DRY CLEAR
9 1 9 0 Hit and Run D Government Property I 0 Fire I &J Photos Taken I 0 Trailer or Towed
9
I 0 Load Spillage I 0 Construction Zone I 0 Names Exchanged 0 Truck, Bus, or Hazardous Materials
101 1102 1103 1 79 -E M S Number 0 Supplemental Reports D Witness Statements D Measurements Taken
Operator/Pedestrian
Unit Status 1 81 -Most Harmful Event: Collision With I 23 -Dir Of Travel 1 24-Speed Limit
MOTOR VEHICLE IN TRANSPORT SOUTH 55
36 -Operating as Classified 1 37 -Endorsements I 35 D CLASS D Operating Commer cial Motor Vehicle
29-Driver's License Number 1 30 -State 1 31-Expiration Year 1 34-On Duty Accident
WI 2015
25-Operator/Pedestrian Last Name I 25 -First Name I ~-Middle Initial I 25 -Suffix
MOELLER COREY
32 -Date Of Birth 1 33-Sex
1 0/05 MALE
26-Address Street & Number 1 26 -PO Box
27-City I 27-State I 27 -Zip Code 1 28 -Telephone Number
HAYWARD WI 54843
39 -Seat Position 140 -Safety Equipment
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR) NONE-USED-VEHICLE-DRIVER/OCCUPANl
38 -Injury Severity 141-Airbag 142 -Ejected 144 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport
43 - Trapped/Extricated I 92- Pedestrian Location I 92 - Pedestrian Action
NOT-TRAPPED
119 -What Driver Was Doing 1120 -Traffic Control I 62 -No. of Citations Issued
GOING-STRAIGHT NO-CONTROL
64-1st Statute No. 1 64 -2nd Statute No. I 64 -3rd Statute No. I 64-4th Statute No. I 64 -5th Statute No.
122 -Driver Factors
OTHER
88 -Driver or Pedestrian Cond I 89 -Substance Presence
APPEARED NORMAL NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
90 -Alcohol Test I 90 -Alcohol Content 1 91 -Drug Test
TEST NOT GIVEN TEST-NOT-GIV EN
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
GZOROF6 Page 2 of 5
..... 0
w _J
2 :I: w >
..... 0
0:: w z ~ 0
:I: w >
..... 0
(/) z -
..... 0
(/) =» m
91 -Drugs Reported
124-Highway Factors
NOT-APPLICABLE
Vehicle
21 -Unit Type
AUTOMOBILE
56 -License Plate Number
JS6662
50 -Year 1 51 -Make
1997 CHEV
94-Vehicle Damage
REAR
95 - Extent Of Damage
VERY-MINOR
123 -Vehicle Factors
NOT-APPLICABLE
Vehicle Owner
45
I Vehicle Type
PASSENGER-CAR
I ~2 -Total Occupants
1 57 -Plate Type 1 58-State I 59 - Exp Year
L TK WI 2014
I 55-Vehicle Identification Number
63635
1 52 -Model
K1500
I 53 - Body Style
TK
1 54-Color
TAN
1100-Skidmarks to Impact (Ft)
1 96 0 Vehicle Towed Due To Damage
1 97-Vehicle Removed By
OWNER
[8] Vehicle Owner Same As Operator
46 -Vehicle Owner Last Name 146 -First Name 1 46 -Middle Initial 146 -Suffix I Date Of Birth
MOELLER COREY M 1 0/05
46 -Company Name
47-Address Street & Number 147 -PO Box
48 -City 148 -State 148 -Zip Code 149 -Telephone Number
HAYWARD WI 54843
Insurance
63 -Liability Insurance Company I ~ STATE-FARM Policy Holder Same As Owner
61 -Policy Holder Last Name I 61 -Policy Holder First Name
MOELLER COREY
61 -Policy Holder Company
School Bus
Bus Travelling to/from I School Name 0 To 0 From
I Body Make I Seating Capacity
School District Contracted With
Operator/Pedestrian
Unit Status 1 81 -Most Harmful Event: Collision With I 23 -Dir Of Travel I 24-Speed Limit
MOTOR VEHICLE IN TRANSPORT SOUTH 55
36 -Operating as Classified 1 37 -Endorsements I 35 D CLASS 0 Operating Commer cial Motor Vehicle
29-Driver's License Number 1 30 -State I 31-Expiration Year 1 34-On Duty Accident
WI 2014
25-Operator/Pedestrian Last Name I 25 -First Name I ~5 -Middle Initial I 25 -Suffix
MILES KEITH
32 -Date Of Birth 1 33-Sex
10/09 MALE
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
GZOROF6 Page 3 of 5
26-Address Street & Number 1 26 -PO Box
27-City I 27-State I 27 -Zip Code 1 28 -Telephone Number
HAYWARD WI 54843
N 39 -Seat Position 140 -Safety Equipment 0 FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR) NONE-USED-VEHICLE-DRIVER/OCC UPANl
z 38 -Injury Severity 141-Airbag 142 -Ejected 144 <( N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport ii: 43-Trapped/Extricated I 92-Pedestrian Location ) 92 -Pedestrian Action .....
t/) NOT-TRAPPED w c 119-VI/hat Driver Was Doing 1120 -Traffic Control I 62 -No. of Citations Issued w GOING-STRAIGHT NO-CONTROL a.. -64-1st Statute No. 1 64 -2nd Statute No. I 64 -3rd Statute No. I 64 -4th Statute No. I 64 -5th Statute No. 0:::
0 .....
<( 122 -Driver Factors
0::: NOT-APPLICABLE w a..
0
88 -Driver or Pedestrian Cond I 89 -Substance Presence
APPEARED NORMAL NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
90 -Alcohol Test I 90 -Alcohol Content ) 91 -Drug Test
TEST NOT GIVEN TEST-NOT-GIV EN
91 -Drugs Reported
124-Highway Factors
NOT-APPLICABLE
Vehicle
21 -Unit Type I Vehicle Type I ~2 -Total Occupants
AUTOMOBILE PASSENGER-CAR
56-License Plate Number 1 57-Plate Type 1 58-State I 59-Exp Year I 55-Vehicle Identification Number
HW3551 L TK WI 2014 96673
N
50 -Year 1 51 -Make
2011 CHEV
1 52 -Model
SILVERADO
I 53 -Body Style
PK
1 54-Color
WHI
1100-Skidmarks to Impact (Ft)
0 94-Vehicle Damage
w FRONT ...J 0
:I: w > 95 - Extent Of Damage I 96 I 97-Vehicle Removed By
MINOR 0 Vehicle Towed Due To Damage OWNER
123-Vehicle Factors
NOT-APPLICABLE
Vehicle Owner
45
N [8J Vehicle Owner Same As Operator
0 46-Vehicle Owner Last Name 146 -First Name 1 46 -Middle Initial 146 -Suffix I Date Of Birth
0::: MILES KEITH H 10/09/1
w 46-Company Name z ~ 0 47-Address Street & Number 147 -PO Box
:I: w > 48 -City 148 -State 148 -Zip Code 149 -Telephone Number
HAYWARD WI 54843
Insurance
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
63 -Liability Insurance Company
GZOROF6
N R.V.I.-NATIONA L-1 NSURANCE-CO
Page 4 of 5
I ~ Policy Holder Same As Owner
0 61 -Policy Holder Last Name I 61 -Policy Holder First Name
(/) MILES KEITH z -61 -Policy Holder Company
School Bus
N Bus Travelling to/from I School Name I Body Make I Seating Capacity 0 0 To 0 From
(/) =» School District Contracted With
al
Occupant
~ Address Same As Operat or
65 -Unit No 1 66 -Occupant Last Name 66 -First Name I ~6 -Middle Initial 1 66 -Suffix
01 MOELLER SARAH
68 -Address Street & Number 68 -PO Box ..... 0
68 -City 68 -State I 68 -Zip Code ..... HAYWARD WI 54843 z <t 67 -Date of Birth 69 -Sex
fl.. 05/14 FEMALE =» 0 71 -Seat Position 1 72-Safety Equipment 0 FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER) NONE-USED-VEHICLE-DRIVER/OCCUPA NT 0
70 -Injury Severity 73 -Airbag I 75 -Ejected
1 77 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport
76 -Trapped/Extricated 78 -Agency Space
NOT-TRAPPED
Occupant
~ Address Same As Operat or
65 -Unit No 1 66 -Occupant Last Name 66 -First Name I ~6 -Middle Initial 1 66 -Suffix
02 MILES MICHAEL
68 -Address Street & Number 68 -PO Box
N 0
68 -City 68 -State I 68 -Zip Code ..... HAYWARD WI 54843 z <t 67 -Date of Birth 69 -Sex
fl.. 08/24 MALE =» 0 71 -Seat Position 1 72-Safety Equipment 0 FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER) NONE-USED-VEHICLE-DRIVER/OCCUPA NT 0
70 -Injury Severity 73 -Airbag I 75 -Ejected 1 77 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED D Medical Transport
76 -Trapped/Extricated 78 -Agency Space
NOT-TRAPPED
Diagram and Narrative
I 1
105 -PHOTOS BY
. JENSEN
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
GZOROF6 Page 5 of 5
z 0
i= ~ 0:::
0 LL z
0::: w 2 LL LL
0
IU
UNIT 2 ~ n;
UNIT 1
A
UNIT 2
8 . .f ~ ~~
UNIT ,r 0
'tEl UNIT 1
~-;
UNIT 1
HIGHWAY 63
UNIT ON E, OPERATED BY MR. MOELLER, WAS TRAVELING SOUTHBOUND ON HIGHWAY 63. MR. MOELLER WAS TRAVELING BELOW
THE SPEED LIMIT WHEN HE SAW THAT MR. MILES WAS OPERATING UNIT TWO. MR. MOELLER SLOWED HIS SPEED THEN
SUDDENLY STOPPED IN THE LAN E OF TRAVEL ON HIGHWAY 63 CAUSING MR. MILES TO REAR END MR. MOELLER. BOTH VEHICLES
SUFFERED MINOR DAMAGE.
Officer Information
125-Officer Last Name 1125 -First Name 1125 -Middle Initial 1131-Officer ID
JENSEN DARIN 387
129 - Law Enforcement Agency No. 1130 -Law Enforcement Agency Name
5700 SAWYER COUNTY SHERIFF
126 -Law Enforcement Agency Address Street & Number
15880 EAST Fl FTH STREET
127 -City 1127 -State 11 27 -Zip Code 1 128-Telephone Number
HAYWARD WI 54843 (715) 634-4858 EXT.
132-Date Notified 1133 -Time Notified (Military Time) 134-Time Arrived (Military Time) 1135 -Date Of Report
12/20/2013 1649 171 3 04/22/2014
Agency Accident Number I Police Number 19-Special Study
13122004
18-Agency Space