20141114 Drissel HeathAgency Accident Number
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Reportable Accident On Emergency Amended GZF999G
DOT Document Number Document Override Number
14111407
14
1
1
1
4
0
7
11/14/2014
4 - Accident Date
2119
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County WINTER - 55, VILLAGE3 - Municipality PARKING LOT11 - Accident Location
14 - On Hwy No.
PARKING LOT
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
07016 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
6520
17 - Structure Number
45.824864
12 - Latitude -91.00941713 - Longitude
PARKED MOTOR VEHICLE80 - First Harmful Event REAR-END93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
UNKNOWN - 9
Surface Type
PARKING-LOT-OR-PRIVATE-PROPERTY115 - Traffic Way
PARKING-LOT-OR-PRIVATE-PROPERTY
117 - Relation To Roadway
DARK-LIGHTED114 - Light Condition ICE116 - Road Surface Condition CLEAR118 - 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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U - UNKNOWN
Unit Status
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With 23 - Dir Of Travel
N/A24 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number 30 - State 31 - Expiration Year 34 - On Duty Accident
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
32 - Date Of Birth 33 - Sex
26 - Address Street & Number 26 - PO Box
27 - City 27 - State
53182
27 - Zip Code 28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
RESTRAINT-USE-UNKNOWN
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
BACKING-MANEUVER
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 062 - 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 NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
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Accident Report
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Wisconsin Motor Vehicle GZF999G 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
490DZD
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2015
59 - Exp Year
8616
55 - Vehicle Identification Number
50 - Year
TOYT
51 - Make
SIENNA
52 - Model
VN - VAN
53 - Body Style
MAR
54 - Color 100 - Skidmarks to Impact (Ft)
REAR DRIVER SIDE, REAR
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
DRISSEL
46 - Vehicle Owner Last Name
ROBERT
46 - First Name
J
46 - Middle Initial 46 - Suffix
01/14/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
UNION GROVE48 - City WI48 - State 5318248 - Zip Code 49 - Telephone Number
NATIONWIDE-INSURANCE-COMPANY-OF-AMERICA63 - Liability Insurance Company Policy Holder Same As Owner60
DRISSEL
61 - Policy Holder Last Name
ROBERT
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
L - LEGALLY PARKED
Unit Status
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With 23 - Dir Of Travel
N/A24 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number 30 - State 31 - Expiration Year 34 - On Duty Accident
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
32 - Date Of Birth 33 - Sex
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZF999G 2 424
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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
27 - City 27 - State 27 - Zip Code 28 - Telephone Number
39 - Seat Position
NOT-APPLICABLE-NONMOTORIST
40 - Safety Equipment
38 - Injury Severity
NOT APPLICABLE
41 - Airbag
NOT-APPLICABLE
42 - Ejected 44
Medical Transport
NOT-APPLICABLE
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
LEGALLY-PARKED
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 62 - 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
88 - Driver or Pedestrian Cond 89 - Substance Presence
90 - Alcohol Test 90 - Alcohol Content 91 - Drug Test
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
0
22 - Total Occupants
397TCC
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2015
59 - Exp Year
1164
55 - Vehicle Identification Number
2011
50 - Year
CHEV
51 - Make
EQUINOX
52 - Model
4H - HATCHBACK 4
53 - Body Style
BRO
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT PASSENGER SIDE, FRONT
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
HEATH
46 - Vehicle Owner Last Name
LINDA
46 - First Name
S
46 - Middle Initial 46 - Suffix
10/28
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
RADISSON48 - City WI48 - State 5486748 - Zip Code 49 - Telephone Number
NOT-REQUIRED63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
61 - Policy Holder Company
02
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02
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZF999G 3 4
School Bus
02
BU
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FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
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
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Diagram and Narrative
UNIT 1 WAS BACKING UP IN PARKING LOT. UNIT 1 HIT PARKED VEHICLE IN PARKING LOT.UNIT 1 WAS BACKING UP IN PARKING LOT. UNIT 1 HIT PARKED VEHICLE IN PARKING LOT.
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125 - First Name 125 - Middle Initial
Officer Information
GILLIS
125 - Officer Last Name
KEVIN 345
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
11/14/2014
132 - Date Notified 2119133 - Time Notified (Military Time)2148134 - Time Arrived (Military Time)
11/14/2014
135 - Date Of Report
14111407 19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZF999G 4 4