20141205 BernardAgency Accident Number
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Reportable Accident On Emergency Amended GZFB1J5
DOT Document Number Document Override Number
14120502
14
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380
38
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12/05/2014
4 - Accident Date
1410
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County SAND LAKE - 14, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
027
14 - On Hwy No.
NB
14 - On Street Name 14 - Bus/Frnt/Rmp
309 FT15 - Est. Distance SOUTH15 - Hwy. Dir
16 - Fr/At Hwy No.OLD 27 RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.876526
12 - Latitude -91.50097113 - Longitude
DITCH80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
OUTSIDE-SHOULDER-RIGHT
117 - Relation To Roadway
DAYLIGHT114 - Light Condition DRY116 - 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
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Unit Status
DITCH
81 - Most Harmful Event: Collision With
NORTH
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
2022
31 - Expiration Year 34 - On Duty Accident
BERNARD
25 - Operator/Pedestrian Last Name
HARLEY
25 - First Name
N
25 - Middle Initial 25 - Suffix
07/06
32 - Date Of Birth
FEMALE
33 - Sex
26 - Address Street & Number 26 - PO Box
HAYWARD
27 - City
WI
27 - State
54843
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
B - NON-INCAPACITATING INJURY
38 - Injury Severity
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.
INATTENTIVE-DRIVING
122 - Driver Factors
NOT OBSERVED88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
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Wisconsin Motor Vehicle GZFB1J5 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
01
22 - Total Occupants
725WMK
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2015
59 - Exp Year
6876
55 - Vehicle Identification Number
2015
50 - Year
KIA
51 - Make
SOUL PLUS
52 - Model
4D - 4DR
53 - Body Style
YEL
54 - Color
00100 - Skidmarks to Impact (Ft)
FRONT, FRONT PASSENGER SIDE, FRONT DRIVER SIDE, TOP OF VEHICLE, REAR
94 - Vehicle Damage
SEVERE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 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
EAN HOLDINGS LLC46 - Company Name
47- Address Street & Number 47 - PO Box
TULSA48 - City OK48 - State 7411748 - Zip Code 49 - Telephone Number
RURAL-MUTUAL-INS-CO-(ATTN:-CLAIMS-DEPT)63 - Liability Insurance Company Policy Holder Same As Owner60
BERNARD
61 - Policy Holder Last Name
HARLEY
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
Trailer
01
TR
L
106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
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Fixed Objects Struck
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Property
GOVERNMENT
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
TOWN OF SAND LAKE
84 - Company Name
COUNTY/MUNICIPAL
Government Property Type
85 - Address Street & Number
6
85 - PO Box
STONE LAKE
86 - City
WI
86 - State
54876
86 - Zip Code 87 - Telephone Number
83 - Government Damage Tag Number
01
82 - Striking Unit
DITCH
82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
105 - Photos By
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Diagram and Narrative
DEPUTY MALCOLM HAAG #380
ON DECEMBER 5TH, 2014 AT APPROXIMATELY 1413 PM I, DEPUTY MALCOLM HAAG, WAS CONTACTED BY SAWYER COUNTY
DISPATCH TO RESPOND TO STATE HWY 27 IN REGARDS TO A SINGLE VEHICLE CRASH WITH POSSIBLE INJURIES. THE CALLER
REPORTED THAT THE INVOLVED VEHICLE HAD ONE OCCUPANT AND THAT THE VEHICLE HAD ROLLED OVER. I ACTIVATED MY
EMERGENCY LIGHTS AND SIRENS AND RESPONDED TO AN AREA ON STATE HWY 27 NEAR THE INTERSECTION OF OLD HWY 27 IN
THE SAND LAKE TOWNSHIP. I OBSERVED A YELLOW FOUR DOOR VEHICLE WITH A FEMALE SITTING OUTSIDE OF THE VEHICLE.
THE FEMALE WAS HARLEY N. BERNARD AND SHE WAS BEING EVALUATED BY FIRST RESPONDERS. THE VEHICLE WAS REPORTED TO HAVE ROLLED NUMEROUS TIMES. HARLEY STATED THAT SHE WAS THE ONLY OCCUPANT AND THERE WERE NO OTHER
VEHICLES INVOLVED. HARLEY WAS TRANSPORTED FROM THE SCENE TO THE HOSPITAL. I PHOTOGRAPHED THE SCENE AND A-1
TOWING REMOVED THE VEHICLE. I CONTACTED DISPATCH THAT I WAS CLEAR OF THE SCENE AT APPROXIMATELY 1506 PM. SEE
CASE 14120502
ON DECEMBER 5TH, 2014 AT APPROXIMATELY 1413 PM I, DEPUTY MALCOLM HAAG, WAS CONTACTED BY SAWYER COUNTY
DISPATCH TO RESPOND TO STATE HWY 27 IN REGARDS TO A SINGLE VEHICLE CRASH WITH POSSIBLE INJURIES. THE CALLER
REPORTED THAT THE INVOLVED VEHICLE HAD ONE OCCUPANT AND THAT THE VEHICLE HAD ROLLED OVER. I ACTIVATED MY
EMERGENCY LIGHTS AND SIRENS AND RESPONDED TO AN AREA ON STATE HWY 27 NEAR THE INTERSECTION OF OLD HWY 27 IN
THE SAND LAKE TOWNSHIP. I OBSERVED A YELLOW FOUR DOOR VEHICLE WITH A FEMALE SITTING OUTSIDE OF THE VEHICLE.
THE FEMALE WAS HARLEY N. BERNARD AND SHE WAS BEING EVALUATED BY FIRST RESPONDERS. THE VEHICLE WAS REPORTED TO HAVE ROLLED NUMEROUS TIMES. HARLEY STATED THAT SHE WAS THE ONLY OCCUPANT AND THERE WERE NO OTHER
VEHICLES INVOLVED. HARLEY WAS TRANSPORTED FROM THE SCENE TO THE HOSPITAL. I PHOTOGRAPHED THE SCENE AND A-1
TOWING REMOVED THE VEHICLE. I CONTACTED DISPATCH THAT I WAS CLEAR OF THE SCENE AT APPROXIMATELY 1506 PM. SEE
CASE 14120502
Officer Information
Accident Report
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Wisconsin Motor Vehicle GZFB1J5 3 4
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125 - First Name 125 - Middle Initial
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
12/05/2014
132 - Date Notified 1413133 - Time Notified (Military Time)1421134 - Time Arrived (Military Time)
12/06/2014
135 - Date Of Report
14120502 380 19 - Special Study
18 - Agency Space
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