20141230 Jack KemmitsAgency Accident Number
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Reportable Accident On Emergency Amended GZDXX63
DOT Document Number Document Override Number
14123005
14
1
2
3
0
0
5
12/30/2014
4 - Accident Date
1304
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 53, CITY3 - Municipality NON-INTERSECTION11 - Accident Location
027
14 - On Hwy No.
SB
14 - On Street Name 14 - Bus/Frnt/Rmp
89 FT15 - Est. Distance NORTH15 - Hwy. Dir
16 - Fr/At Hwy No.RAILROAD ST16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.012560
12 - Latitude -91.48411913 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event SIDESWIPE. SAME DIRECTION93 - 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
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
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Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
SOUTH
23 - Dir Of Travel
2524 - 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
JACK
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
01/23/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
STONE LAKE
27 - City
WI
27 - State
54876
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
CHANGING-LANES
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 0262 - No. of Citations Issued
344.62(1)
64 - 1st Statute No.
346.13(1)
64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
INATTENTIVE-DRIVING
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
01
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDXX63 1 4
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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
911VEF
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2015
59 - Exp Year
0684
55 - Vehicle Identification Number
2005
50 - Year
DODG
51 - Make
CARAVAN
52 - Model
4D - 4DR
53 - Body Style
SIL
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT PASSENGER SIDE, MIDDLE PASSENGER SIDE
94 - Vehicle Damage
MINOR
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
GROVER
46 - Vehicle Owner Last Name
TAMARA
46 - First Name
NMI
46 - Middle Initial 46 - Suffix
08/08
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
STONE LAKE48 - City WI48 - State 5487648 - Zip Code 49 - Telephone Number
UNKNOWN63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 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
2524 - 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
KEMMITS
25 - Operator/Pedestrian Last Name
SARAH
25 - First Name
A
25 - Middle Initial 25 - Suffix
04/29/
32 - Date Of Birth
FEMALE
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 GZDXX63 2 424
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IN
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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
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 NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
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
01
22 - Total Occupants
474NNL
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2015
59 - Exp Year
0913
55 - Vehicle Identification Number
2006
50 - Year
FORD
51 - Make
FUSION
52 - Model
4D - 4DR
53 - Body Style
RED
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE, MIDDLE DRIVER SIDE, REAR DRIVER SIDE
94 - Vehicle Damage
MINOR
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
KEMMITS
46 - Vehicle Owner Last Name
WILLIAM
46 - First Name
G
46 - Middle Initial 46 - Suffix
08/29/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
EXELAND48 - City WI48 - State 5483548 - Zip Code 49 - Telephone Number
ALLSTATE63 - Liability Insurance Company Policy Holder Same As Owner60
KEMMITS
61 - Policy Holder Last Name
WILLIAM
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDXX63 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
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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
UNIT 1 AND UNIT 2 WERE TRAVELING SOUTHBOUND ON HIGHWAY 27. UNIT 1 CHANGED LANES FROM THE EAST TO THE WEST. WHILE DOING THIS UNIT 1 SIDE SWIPED UNIT 2.UNIT 1 AND UNIT 2 WERE TRAVELING SOUTHBOUND ON HIGHWAY 27. UNIT 1 CHANGED LANES FROM THE EAST TO THE WEST. WHILE DOING THIS UNIT 1 SIDE SWIPED UNIT 2.
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125 - First Name 125 - Middle Initial
Officer Information
CULHANE
125 - Officer Last Name
CASEY 327
131 - Officer ID
206129 - Law Enforcement Agency No.SAWYER COUNTY SHERIFFS DEPT130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET
126 - Law Enforcement Agency Address Street & Number
HAYWARD127 - City WI127 - State 54843127 - Zip Code (715) 634-4858 EXT. 128 - Telephone Number
12/30/2014
132 - Date Notified 1304133 - Time Notified (Military Time)1325134 - Time Arrived (Military Time)
01/05/2015
135 - Date Of Report
14123005 19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZDXX63 4 4