20160121 Larsen ClaussAgency Accident Number
AC
C
I
D
E
N
T
#
PO
L
I
C
E
#
Police Number
GE
N
E
R
A
L
I
N
F
O
R
M
A
T
I
O
N
Reportable Accident On Emergency Amended GZDVPJM
DOT Document Number Document Override Number
16012100776
16
0
1
2
1
0
0
7
7
6
16012101
16
0
1
2
1
0
1
01/21/2016
4 - Accident Date
0929
5 - Time of Accident (Military Time)
02
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County LENROOT - 08, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
JOLLY FISHERMAN RD
14 - On Street Name 14 - Bus/Frnt/Rmp
689 FT15 - Est. Distance EAST15 - Hwy. Dir
02716 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.107143
12 - Latitude -91.50687313 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event SIDESWIPE. OPPOSITE 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 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
1601210077679 - E M S Number
Operator/Pedestrian
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
Unit Status
MOTOR VEHICLE IN TRANSPORT
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
2018
31 - Expiration Year 34 - On Duty Accident
LARSEN
25 - Operator/Pedestrian Last Name
TAMARA
25 - First Name
R
25 - Middle Initial 25 - Suffix
03/11/
32 - Date Of Birth
FEMALE
33 - Sex
26 - Address Street & Number 26 - PO Box
MINONG
27 - City
WI
27 - State
54859
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 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.
FAILURE-TO-HAVE-CONTROL
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 GZDVPJM 1 4
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
224MML
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
6424
55 - Vehicle Identification Number
2011
50 - Year
FORD
51 - Make
ESCAPE
52 - Model
UT - SPORT UTILITY
53 - Body Style
BLK
54 - Color
60100 - Skidmarks to Impact (Ft)
MIDDLE PASSENGER SIDE
94 - Vehicle Damage
MODERATE
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
HARWICK
46 - Vehicle Owner Last Name
MIKEL
46 - First Name
R
46 - Middle Initial 46 - Suffix
10/02
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
PROGRESSIVE-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
HARWICK
61 - Policy Holder Last Name
MIKEL
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
NORTH
23 - Dir Of Travel
5524 - Speed Limit
O CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
CLAUSS
25 - Operator/Pedestrian Last Name
LEROY
25 - First Name
P
25 - Middle Initial 25 - Suffix
08/31/
32 - Date Of Birth
MALE
33 - Sex
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJM 2 424
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
IN
S
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
RESTRAINT-USE-UNKNOWN
40 - Safety Equipment
A - INCAPACITATING INJURY
38 - Injury Severity
NOT APPLICABLE
41 - Airbag
TOTALLY-EJECTED
42 - Ejected 44
Medical Transport
NOT-TRAPPED
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
OTHER
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.
FAIL-TO-YIELD-RIGHT-OF-WAY, INATTENTIVE-DRIVING
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
SNOW,-ICE,-OR-WET
124 - Highway Factors
EQUIPMENT
21 - Unit Type
OTHER-WORKING-MACHINE
Vehicle Type
1
22 - Total Occupants
56 - License Plate Number 57 - Plate Type 58 - State 59 - Exp Year 55 - Vehicle Identification Number
50 - Year 51 - Make
CRAFTSMAN
52 - Model
MO - MOWER
53 - Body Style
TAN
54 - Color
0100 - Skidmarks to Impact (Ft)
REAR PASSENGER SIDE
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OWNER
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
CLAUSS
46 - Vehicle Owner Last Name
LEROY
46 - First Name
P
46 - Middle Initial 46 - Suffix
08/31/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - 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
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJM 3 4
School Bus
02
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
105 - Photos By
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
POPLIN 352
ON JANUARY 21ST, 2016 UNIT 1 WAS GOING WEST ON ICE COVERED JOLLY FISHERMAN ROAD. UNIT 1 SAW UNIT 2 SNOW BLOWING THE DRIVEWAY AND THOUGHT UNIT 2 WAS GOING TO STOP BEFORE COMING INTO THE ROAD. UNIT 2 DIDN'T STOP AND KEPT
COMING INTO THE ROADWAY AND UNIT 1 ATTEMPTED TO STOP BY BRAKING. THE ICY CONDITIONS CAUSED UNIT 1 TO SLIDE AND
THE DRIVER OF UNIT 1 SAID SHE VEERED LEFT TO TRY NOT TO HIT UNIT 2. UNIT 1 STRUCK UNIT 2 CAUSING MODERATE DAMAGE
TO BOTH VEHICLES AND THE DRIVER OF UNIT 2 WAS EJECTED OFF OF THE VEHICLE. THE DRIVER OF UNIT 2 WAS TRANSPORTED
BY AMBULANCE TO THE HOSPITAL.
ON JANUARY 21ST, 2016 UNIT 1 WAS GOING WEST ON ICE COVERED JOLLY FISHERMAN ROAD. UNIT 1 SAW UNIT 2 SNOW BLOWING THE DRIVEWAY AND THOUGHT UNIT 2 WAS GOING TO STOP BEFORE COMING INTO THE ROAD. UNIT 2 DIDN'T STOP AND KEPT
COMING INTO THE ROADWAY AND UNIT 1 ATTEMPTED TO STOP BY BRAKING. THE ICY CONDITIONS CAUSED UNIT 1 TO SLIDE AND
THE DRIVER OF UNIT 1 SAID SHE VEERED LEFT TO TRY NOT TO HIT UNIT 2. UNIT 1 STRUCK UNIT 2 CAUSING MODERATE DAMAGE
TO BOTH VEHICLES AND THE DRIVER OF UNIT 2 WAS EJECTED OFF OF THE VEHICLE. THE DRIVER OF UNIT 2 WAS TRANSPORTED
BY AMBULANCE TO THE HOSPITAL.
OF
F
I
C
E
R
I
N
F
O
R
M
A
T
I
O
N
125 - First Name 125 - Middle Initial
Officer Information
POPLIN
125 - Officer Last Name
JAY 352
131 - Officer ID
129 - 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
01/21/2016
132 - Date Notified 0929133 - Time Notified (Military Time)0937134 - Time Arrived (Military Time)
01/21/2016
135 - Date Of Report
16012100776 16012101 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJM 4 4