20160127 Kohnke MayouAgency Accident Number
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Reportable Accident On Emergency Amended GZDWFR6
DOT Document Number Document Override Number
16012704
16
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1
2
7
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01/27/2016
4 - Accident Date
1220
5 - Time of Accident (Military Time)
02
6 - Total Units 7 - Total Injured 8 - Total Killed
SAWYER - 572 - County HAYWARD - 53, CITY3 - Municipality INTERSECTION11 - Accident Location
063
14 - On Hwy No.
NB
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
16 - Fr/At Hwy No.MINNESOTA AVE16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.011662
12 - Latitude -91.48675413 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event ANGLE93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
CONCRETE - 1
Surface Type
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
ON-ROADWAY
117 - Relation To Roadway
DAYLIGHT114 - Light Condition SNOW/SLUSH116 - Road Surface Condition CLOUDY118 - 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
NORTH
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
2019
31 - Expiration Year 34 - On Duty Accident
KOHNKE
25 - Operator/Pedestrian Last Name
JUDITH
25 - First Name
E
25 - Middle Initial 25 - Suffix
07/23/
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
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.
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
01
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFR6 1 4
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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
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
SNOWDOG
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
3191
55 - Vehicle Identification Number
2010
50 - Year
CHEV
51 - Make
IMPALA
52 - Model
4D - 4DR
53 - Body Style
BLU
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT
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
KOHNKE
46 - Vehicle Owner Last Name
JUDITH
46 - First Name
E
46 - Middle Initial 46 - Suffix
07/23
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
AMICA-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
KOHNKE
61 - Policy Holder Last Name
JUDITH
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
2524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
r
WI
30 - State
2019
31 - Expiration Year 34 - On Duty Accident
MAYOU
25 - Operator/Pedestrian Last Name
PETER
25 - First Name
A
25 - Middle Initial 25 - Suffix
05/22/
32 - Date Of Birth
MALE
33 - Sex
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 GZDWFR6 2 424
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Vehicle Owner
Insurance
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IN
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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
STOP-SIGN
120 - Traffic Control 162 - No. of Citations Issued
346.18(3)
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
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
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
JB1971
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2016
59 - Exp Year
9249
55 - Vehicle Identification Number
2006
50 - Year
NISS
51 - Make
TITAN
52 - Model
PK - PICKUP
53 - Body Style
GRY
54 - Color 100 - Skidmarks to Impact (Ft)
MIDDLE PASSENGER SIDE, 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
MAYOU
46 - Vehicle Owner Last Name
PETER
46 - First Name
A
46 - Middle Initial 46 - Suffix
05/22/
Date Of Birth
46 - Company Name
47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code .49 - Telephone Number
AUTO-OWNERS-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
MAYOU
61 - Policy Holder Last Name
PETER
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFR6 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
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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 1 WAS NORTHBOUND IN THE OUTSIDE LANE OF HWY 63 WHEN UNIT 2 TRAVELING EAST ON MINNESOTA AVE CROSSED IN FRONT OF UNIT 1 WITH YIELDING UNIT 1 WAS NORTHBOUND IN THE OUTSIDE LANE OF HWY 63 WHEN UNIT 2 TRAVELING EAST ON MINNESOTA AVE CROSSED IN FRONT OF UNIT 1 WITH YIELDING
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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 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
01/27/2016
132 - Date Notified 1220133 - Time Notified (Military Time)1220134 - Time Arrived (Military Time)
01/28/2016
135 - Date Of Report
16012704 19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFR6 4 4