20141221 StrickerAgency Accident Number
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Reportable Accident On Emergency Amended GZDWFQP
DOT Document Number Document Override Number
14122106
14
1
2
2
1
0
6
12/21/2014
4 - Accident Date
1239
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County ROUND LAKE - 13, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
077
14 - On Hwy No.
WB
14 - On Street Name 14 - Bus/Frnt/Rmp
521 FT15 - Est. Distance NORTH15 - Hwy. Dir
16 - Fr/At Hwy No.HILDRETH RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.057159
12 - Latitude -91.31525813 - Longitude
OVERTURN80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - 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
OUTSIDE-SHOULDER-RIGHT
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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Unit Status
OVERTURN
81 - Most Harmful Event: Collision With
WEST
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
2016
31 - Expiration Year 34 - On Duty Accident
STRICKER
25 - Operator/Pedestrian Last Name
JEREMY
25 - First Name
J
25 - Middle Initial 25 - Suffix
11/19/1
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
MELLEN
27 - City
WI
27 - State
54546
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 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.
SPEED-TOO-FAST-FOR-CONDITIONS
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
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFQP 1 3
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
2
22 - Total Occupants
JX3281
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2015
59 - Exp Year
0822
55 - Vehicle Identification Number
2009
50 - Year
NISS
51 - Make
TITAN
52 - Model
PK - PICKUP
53 - Body Style
GRY
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE, REAR DRIVER 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
STRICKER
46 - Vehicle Owner Last Name
JEREMY
46 - First Name
J
46 - Middle Initial 46 - Suffix
11/19
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
MELLEN48 - City WI48 - State 5454648 - Zip Code 49 - Telephone Number
WISCONSIN-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
STRICKER
61 - Policy Holder Last Name
JEREMY
61 - Policy Holder First Name
61 - Policy Holder Company
01
01
01
01
BU
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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
S
66 - Occupant Last Name
J
66 - First Name 66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
MELLEN
68 - City
WI
68 - State
54546
68 - Zip Code
12/1967 - Date of Birth M69 - Sex
SECOND-SEAT-LEFT-SIDE-(MC/BIKE PASSENGER, TRAIN BREAKMA
71 - Seat Position
CHILD-SAFETY-SEAT-USED
72 - Safety Equipment
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFQP 2 323
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
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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
DEPUTY JEFF CAIN
UNIT ONE WAS WEST BOUND ON HWY 77 AT APPROXIMATELY 52 MPH WHEN THE DRIVER LOST CONTROL ON THE SNOW COVERED ROADWAY. UNIT ONE TURNED FACING EAST AND WENT INTO THE WEST BOUND DITCH SIDEWAYS CAUSING IT TO ROLL
ONTO IT'S LEFT SIDE.
UNIT ONE WAS WEST BOUND ON HWY 77 AT APPROXIMATELY 52 MPH WHEN THE DRIVER LOST CONTROL ON THE SNOW COVERED ROADWAY. UNIT ONE TURNED FACING EAST AND WENT INTO THE WEST BOUND DITCH SIDEWAYS CAUSING IT TO ROLL
ONTO IT'S LEFT SIDE.
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125 - First Name 125 - Middle Initial
Officer Information
CAIN
125 - Officer Last Name
JEFF 314
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
12/21/2014
132 - Date Notified 1239133 - Time Notified (Military Time)1253134 - Time Arrived (Military Time)
12/23/2014
135 - Date Of Report
14122106 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFQP 3 3