20141110 Moser TremblayAgency Accident Number
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Reportable Accident On Emergency Amended GZFB1J4
DOT Document Number Document Override Number
14111009
14
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14111009
14
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11/10/2014
4 - Accident Date
0205
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County SAND LAKE - 14, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
027
14 - On Hwy No.
SB
14 - On Street Name 14 - Bus/Frnt/Rmp
901 FT15 - Est. Distance WEST15 - Hwy. Dir
16 - Fr/At Hwy No.BREEZY POINT LN16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.850860
12 - Latitude -91.44647313 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event REAR-END93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
HILL
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
ON-ROADWAY
117 - Relation To Roadway
DAYLIGHT114 - Light Condition SNOW/SLUSH116 - Road Surface Condition SNOW118 - Weather
Hit and Run
9
Government Property
9
Fire
9
Photos Taken
9
Trailer or Towed
9
Truck, Bus, or Hazardous Materials
9
Load Spillage
9
Construction Zone
9
Names Exchanged
9
Supplemental Reports
101
Witness Statements
102
Measurements Taken
103 79 - E M S Number
Operator/Pedestrian
OP
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P
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Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
SOUTH
23 - Dir Of Travel
5524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2017
31 - Expiration Year 34 - On Duty Accident
MOSER
25 - Operator/Pedestrian Last Name
REBECCA
25 - First Name
A
25 - Middle Initial 25 - Suffix
10/05 FEMALE
33 - Sex
26 - Address Street & Number 26 - PO Box
RADISSON
27 - City
WI
27 - State
54867
27 - Zip Code 28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
40 - Safety Equipment
N - NO APPARENT INJURY
38 - Injury Severity
NON-DEPLOYED
41 - Airbag
NOT-EJECTED
42 - Ejected 44
Medical Transport
NOT-TRAPPED
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
GOING-STRAIGHT
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 0062 - No. of Citations Issued
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
NOT-APPLICABLE
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
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Wisconsin Motor Vehicle GZFB1J4 1 5
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
02
22 - Total Occupants
610SDN
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2014
59 - Exp Year
8185
55 - Vehicle Identification Number
2008
50 - Year
CHEV
51 - Make
UPLANDER
52 - Model
VN - VAN
53 - Body Style
GRY
54 - Color
00100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE
94 - Vehicle Damage
MINOR
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OPERATOR
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
KINSLEY
46 - Vehicle Owner Last Name
RUSSELL
46 - First Name
V
46 - Middle Initial 46 - Suffix
01/17
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
RADISSON48 - City WI48 - State 5486748 - Zip Code 49 - Telephone Number
MT-MORRIS-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
KINSLEY
61 - Policy Holder Last Name
RUSSELL
61 - Policy Holder First Name
61 - Policy Holder Company
01
01
01
01
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Operator/Pedestrian
Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
SOUTH
23 - Dir Of Travel
5524 - Speed Limit
B CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2017
31 - Expiration Year 34 - On Duty Accident
TREMBLAY
25 - Operator/Pedestrian Last Name
ERIC
25 - First Name
L
25 - Middle Initial 25 - Suffix
06/27/
32 - Date Of Birth
MALE
33 - Sex
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZFB1J4 2 525
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Vehicle
Vehicle Owner
Insurance
OP
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IN
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26 - Address Street & Number 26 - PO Box
HAWKINS
27 - City
WI
27 - State
54530
27 - Zip Code 28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
40 - Safety Equipment
N - NO APPARENT INJURY
38 - Injury Severity
NON-DEPLOYED
41 - Airbag
NOT-EJECTED
42 - Ejected 44
Medical Transport
NOT-TRAPPED
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
OVERTAKING-ON-LEFT
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 0062 - No. of Citations Issued
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
NOT-APPLICABLE
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
TRUCK
21 - Unit Type
STRAIGHT-TRUCK-(INSERT TRUCK)
Vehicle Type
01
22 - Total Occupants
HD20462
56 - License Plate Number
HTK57 - Plate Type WI
58 - State
2014
59 - Exp Year
2459
55 - Vehicle Identification Number
2000
50 - Year
STLG
51 - Make
HVY TRK
52 - Model
TK - TRUCK
53 - Body Style
WHI
54 - Color
00100 - Skidmarks to Impact (Ft)
REAR PASSENGER SIDE
94 - Vehicle Damage
VERY-MINOR
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OPERATOR
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
46 - Vehicle Owner Last Name 46 - First Name 46 - Middle Initial 46 - Suffix Date Of Birth
MIX RITE TRANSPORT LLC46 - Company Name
47- Address Street & Number 47 - PO Box
KENNAN48 - City WI48 - State 5453748 - Zip Code 49 - Telephone Number
AG-SECURITY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
MIX RITE TRANSPORT LLC61 - Policy Holder Company
02
02
02
02
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Wisconsin Motor Vehicle GZFB1J4 3 5
School Bus
02
BU
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FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Occupant
Address Same As Operator
OC
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01
65 - Unit No
MLECZKO
66 - Occupant Last Name
DIANA
66 - First Name
L
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number
174
68 - PO Box
RADISSON
68 - City
WI
68 - State
54867
68 - Zip Code
01/21/
67 - Date of Birth
F
69 - Sex
FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER)
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
72 - Safety Equipment
N - NO APPARENT INJURY
70 - Injury Severity
NON-DEPLOYED
73 - Airbag
NOT-EJECTED
75 - Ejected
Medical Transport
77
NOT-TRAPPED
76 - Trapped/Extricated 78 - Agency Space
Trailer
01
TR
L
106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
105 - Photos By
DI
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Diagram and Narrative
DEPUTY HAAG #380
ON NOVEMBER 10, 2014 AT APPROXIMATELY 1405 PM A CRASH OCCURRED ON STATE HWY 2770 NEAR BREEZY POINT RD WITH NO
INJURIES. UNIT 01 REPORTED TO BE TRAVELING AT APPROXIMATELY 5 MPH UP A HILL AND UNIT 02 WAS BEHIND UNIT 01
TRAVELING AT APPROXIMATELY 25 MPH. UNIT 01 BEGAN LOSING TRACTION IN THE SNOW AND ICE
ON NOVEMBER 10, 2014 AT APPROXIMATELY 1405 PM A CRASH OCCURRED ON STATE HWY 2770 NEAR BREEZY POINT RD WITH NO
INJURIES. UNIT 01 REPORTED TO BE TRAVELING AT APPROXIMATELY 5 MPH UP A HILL AND UNIT 02 WAS BEHIND UNIT 01
TRAVELING AT APPROXIMATELY 25 MPH. UNIT 01 BEGAN LOSING TRACTION IN THE SNOW AND ICE
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Wisconsin Motor Vehicle GZFB1J4 4 5
CONDITIONS ON THE ROADWAY UP THE HILL AND BEGAN DECREASING SPEED. UNIT 02 ATTEMPTED TO PASS UNIT 01 TO MAINTAIN MOMENTUM UP THE HILL IN THE WINTERY CONDITIONS. AS UNIT 02 WAS PASSING UNIT 01, UNIT 02 BEGAN TO SLIDE
AND CONTACTED UNIT 01. BOTH VEHICLES PULLED OFF TO THE SIDE OF THE ROADWAY.
CONDITIONS ON THE ROADWAY UP THE HILL AND BEGAN DECREASING SPEED. UNIT 02 ATTEMPTED TO PASS UNIT 01 TO MAINTAIN MOMENTUM UP THE HILL IN THE WINTERY CONDITIONS. AS UNIT 02 WAS PASSING UNIT 01, UNIT 02 BEGAN TO SLIDE
AND CONTACTED UNIT 01. BOTH VEHICLES PULLED OFF TO THE SIDE OF THE ROADWAY.
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125 - First Name 125 - Middle Initial
Officer Information
HAAG
125 - Officer Last Name
MALCOLM 380
131 - Officer ID
129 - Law Enforcement Agency No.
SAWYER COUNTY SHERIFFS DEPT
130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET
126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4858 EXT.
128 - Telephone Number
11/10/2014
132 - Date Notified 1410133 - Time Notified (Military Time)1424134 - Time Arrived (Military Time)
11/10/2014
135 - Date Of Report
14111009 14111009 19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
Page
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Wisconsin Motor Vehicle GZFB1J4 5 5