20141212 Peterson SchockAgency Accident Number
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Reportable Accident On Emergency Amended GZDSGV1
DOT Document Number Document Override Number
14121201
14
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2
1
2
0
1
380
38
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12/12/2014
4 - Accident Date
1028
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 INTERSECTION11 - Accident Location
070
14 - On Hwy No.
EB
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
02716 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.863121
12 - Latitude -91.50200213 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event SIDESWIPE. SAME DIRECTION93 - Manner of Collision
FULL 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
ON-ROADWAY
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
OP
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Unit Status
MOTOR VEHICLE IN TRANSPORT
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
MN
30 - State
2016
31 - Expiration Year 34 - On Duty Accident
PETERSON
25 - Operator/Pedestrian Last Name
CHRISTOPHER
25 - First Name
LEE
25 - Middle Initial 25 - Suffix
01/09/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
EXCELSIOR
27 - City
MN
27 - State
55331
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
MAKING-LEFT-TURN
119 - What Driver Was Doing
STOP-SIGN
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
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
01
22 - Total Occupants
937DEE
56 - License Plate Number
AUT57 - Plate Type MN
58 - State
2015
59 - Exp Year
0131
55 - Vehicle Identification Number
2003
50 - Year
JEEP
51 - Make
4W LIBERTY
52 - Model
4D - 4DR
53 - Body Style
BRO
54 - Color
00100 - Skidmarks to Impact (Ft)
OTHER
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
PETERSON
46 - Vehicle Owner Last Name
LEE
46 - First Name
RUSSELL
46 - Middle Initial 46 - Suffix
07/09/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
EXCELSIOR48 - City MN48 - State 5533148 - Zip Code 49 - Telephone Number
USAA-GENERAL-INDEMNITY-CO63 - Liability Insurance Company Policy Holder Same As Owner60
PETERSON
61 - Policy Holder Last Name
LEE
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
EAST
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
SCHOCK
25 - Operator/Pedestrian Last Name
DAVID
25 - First Name
L
25 - Middle Initial 25 - Suffix
03/29/
32 - Date Of Birth
MALE
33 - Sex
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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
EAU CLAIRE
27 - City
WI
27 - State
54701
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
STOP-SIGN
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
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
02
22 - Total Occupants
FB24597
56 - License Plate Number
HTK57 - Plate Type WI
58 - State
2015
59 - Exp Year
4249
55 - Vehicle Identification Number
2008
50 - Year
FORD
51 - Make
F550 SUPER
52 - Model
CB - CAB CHASSIS
53 - Body Style
WHI
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
BRAKE-SYSTEM
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
GELCO CORPORATION46 - Company Name
3 CAPITAL DR
47- Address Street & Number 47 - PO Box
EDEN PRAIRIE48 - City MN48 - State 5534448 - Zip Code 49 - Telephone Number
LIBERTY-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
GELCO CORPORATION61 - Policy Holder Company
02
02
02
02
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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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02
65 - Unit No
WEBSTER
66 - Occupant Last Name
DENNIS
66 - First Name
D
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
GILMAN
68 - City
WI
68 - State
54433
68 - Zip Code
09/20/1
67 - Date of Birth
M
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
1
106 - Power Unit Number
937DEE
License Plate Number
AUT
Plate Type
MN
State
2015
Expiration Year
JEEPTrailer Make AUTOUnit Type 0131Vehicle Identification Number
105 - Photos By
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Diagram and Narrative
DEPUTY MALCOLM HAAG #380
ON DECEMBER 12TH, 2014 AT APPROXIMATELY 1033 AM I, DEPUTY MALCOLM HAAG, WAS CONTACTED BY DISPATCH IN REGARDS
TO A TWO VEHICLE CRASH IN STONE LAKE. DISPATCH ALERTED ME THAT THE VEHICLES WERE CLEAR OF THE ROADWAY AND
THERE WAS NOT ANY REPORTED INJURIES. I ARRIVED ON SCENE AT APPROXIMATELY 1047 AM. I
ON DECEMBER 12TH, 2014 AT APPROXIMATELY 1033 AM I, DEPUTY MALCOLM HAAG, WAS CONTACTED BY DISPATCH IN REGARDS
TO A TWO VEHICLE CRASH IN STONE LAKE. DISPATCH ALERTED ME THAT THE VEHICLES WERE CLEAR OF THE ROADWAY AND
THERE WAS NOT ANY REPORTED INJURIES. I ARRIVED ON SCENE AT APPROXIMATELY 1047 AM. I
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MADE CONTACT WITH BOTH DRIVERS AND CONTACTED DISPATCH WITH THEIR DRIVER'S AND VEHICLE INFORMATION. THE OPERATOR OF UNIT 02 HAD A PASSENGER IN THE PASSENGER SIDE FRONT SEAT DURING THE CRASH. ALL INDIVIDUALS ON
SCENE REPORTED THAT THEY WERE NOT INJURED OR REQUIRED EMS SERVICES. THE OPERATOR OF UNIT 01 STATED THAT HE
WAS PULLING A RECREATIONAL TRAILER AND WAS TURNING FROM STATE HWY 70 ONTO STATE HWY 27 NORTHBOUND. HE
STATED THAT HE STOPPED AT THE STOP SIGN AND AS HE MERGED ONTO 27 NORTHBOUND NOTICED THAT HIS TRAILER HAD
BEEN STRUCK. HE PULLED INTO THE NEARBY GAS STATION TO MAKE CONTACT WITH THE OTHER VEHICLE OPERATOR. THE
OPERATOR OF UNIT 02 STATED THAT AS HE WAS SLOWING FOR THE STOP SIGN, HIS BRAKES FAILED AND THE VEHICLE'S ENGINE REVVED HIGH RPM'S. THE OPERATOR OF UNIT 02 STATED THAT HE WAS DEPRESSING THE BRAKE PEDAL STRONGLY AND WAS
UNABLE TO STOP THE VEHICLE. HIS VEHICLE MADE CONTACT ONLY WITH THE REAR PASSENGER SIDE OF THE TRAILER. HE MET
THE OPERATOR OF UNIT 01 AT THE GAS STATION AND THEY EXCHANGED INFORMATION AND CONTACTED DISPATCH. THE
OPERATOR OF UNIT 02 WAS GOING TO CONTACT HIS SUPERVISOR AND A TOW TO HAVE THE VEHICLE CHECKED AFTER I
DEPARTED THE SCENE. I PHOTOGRAPHED THE SCENE AND DEPARTED AT APPROXIMATELY 1110 AM. SEE CASE 14121201
MADE CONTACT WITH BOTH DRIVERS AND CONTACTED DISPATCH WITH THEIR DRIVER'S AND VEHICLE INFORMATION. THE OPERATOR OF UNIT 02 HAD A PASSENGER IN THE PASSENGER SIDE FRONT SEAT DURING THE CRASH. ALL INDIVIDUALS ON
SCENE REPORTED THAT THEY WERE NOT INJURED OR REQUIRED EMS SERVICES. THE OPERATOR OF UNIT 01 STATED THAT HE
WAS PULLING A RECREATIONAL TRAILER AND WAS TURNING FROM STATE HWY 70 ONTO STATE HWY 27 NORTHBOUND. HE
STATED THAT HE STOPPED AT THE STOP SIGN AND AS HE MERGED ONTO 27 NORTHBOUND NOTICED THAT HIS TRAILER HAD
BEEN STRUCK. HE PULLED INTO THE NEARBY GAS STATION TO MAKE CONTACT WITH THE OTHER VEHICLE OPERATOR. THE
OPERATOR OF UNIT 02 STATED THAT AS HE WAS SLOWING FOR THE STOP SIGN, HIS BRAKES FAILED AND THE VEHICLE'S ENGINE REVVED HIGH RPM'S. THE OPERATOR OF UNIT 02 STATED THAT HE WAS DEPRESSING THE BRAKE PEDAL STRONGLY AND WAS
UNABLE TO STOP THE VEHICLE. HIS VEHICLE MADE CONTACT ONLY WITH THE REAR PASSENGER SIDE OF THE TRAILER. HE MET
THE OPERATOR OF UNIT 01 AT THE GAS STATION AND THEY EXCHANGED INFORMATION AND CONTACTED DISPATCH. THE
OPERATOR OF UNIT 02 WAS GOING TO CONTACT HIS SUPERVISOR AND A TOW TO HAVE THE VEHICLE CHECKED AFTER I
DEPARTED THE SCENE. I PHOTOGRAPHED THE SCENE AND DEPARTED AT APPROXIMATELY 1110 AM. SEE CASE 14121201
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125 - First Name 125 - Middle Initial
Officer Information
HAAG125 - Officer Last Name MALCOLM 380131 - Officer ID
129 - Law Enforcement Agency No.
SAWYER COUNTY SHERIFFS DEPT
130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4858 EXT.
128 - Telephone Number
12/12/2014132 - Date Notified 1033133 - Time Notified (Military Time)1047134 - Time Arrived (Military Time)12/25/2014135 - Date Of Report
14121201 380 19 - Special Study
18 - Agency Space
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