20160223 Schultz OzeeAgency Accident Number
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Reportable Accident On Emergency Amended GZDVPJP
DOT Document Number Document Override Number
16022302169
16
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2
2
3
0
2
1
6
9
16022303
16
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02/23/2016
4 - Accident Date
1456
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County BASS LAKE - 01, TOWN3 - Municipality INTERSECTION11 - Accident Location
14 - On Hwy No.
STONE LAKE RD
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
16 - Fr/At Hwy No.PRIVATE PROPERTY16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
7076N
17 - Structure Number
45.900214
12 - Latitude -91.54146413 - 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
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 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
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Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
WEST
23 - Dir Of Travel
N/A24 - 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
SCHULTZ
25 - Operator/Pedestrian Last Name
KELSY
25 - First Name
RAE
25 - Middle Initial 25 - Suffix
04/10/
32 - Date Of Birth
FEMALE
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
SLOWING-OR-STOPPING
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.
SPEED-TOO-FAST-FOR-CONDITIONS, 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
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Vehicle
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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
381XKJ
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
529
55 - Vehicle Identification Number
2002
50 - Year
NISS
51 - Make
ALTIMA
52 - Model
4D - 4DR
53 - Body Style
GLD
54 - Color
10100 - Skidmarks to Impact (Ft)
FRONT
94 - Vehicle Damage
SEVERE
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
SCHULTZ
46 - Vehicle Owner Last Name
KELSY
46 - First Name
RAE
46 - Middle Initial 46 - Suffix
04/10/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
STONE LAKE48 - City WI48 - State 5487648 - Zip Code (715) 558-6948 EXT.49 - Telephone Number
PROGRESSIVE-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
SCHULTZ
61 - Policy Holder Last Name
KELSY
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
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
OZEE
25 - Operator/Pedestrian Last Name
TANYA
25 - First Name
J
25 - Middle Initial 25 - Suffix
03/27/
32 - Date Of Birth
FEMALE
33 - Sex
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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
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.
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
SNOW,-ICE,-OR-WET
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
552WMP
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
4888
55 - Vehicle Identification Number
2009
50 - Year
BUIC
51 - Make
ENCLAVE
52 - Model
UT - SPORT UTILITY
53 - Body Style
WHI
54 - Color
25100 - Skidmarks to Impact (Ft)
FRONT PASSENGER SIDE, MIDDLE PASSENGER SIDE
94 - Vehicle Damage
SEVERE
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
OZEE
46 - Vehicle Owner Last Name
TANYA
46 - First Name
J
46 - Middle Initial 46 - Suffix
03/27/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
STONE LAKE48 - City WI48 - State 5487648 - Zip Code .49 - Telephone Number
STATE-FARM63 - Liability Insurance Company Policy Holder Same As Owner60
OZEE
61 - Policy Holder Last Name
TANYA
61 - Policy Holder First Name
61 - 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
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
POPLIN
UNIT 1 WAS LEAVING THE DRIVEWAY OF 7076N STONE LAKE ROAD. UNIT 2 WAS GOING NORTH ON STONE LAKE ROAD. DUE TO ICY ROAD AND DRIVEWAY CONDITIONS UNIT 1 SLID PAST THE DRIVEWAY STRIKING THE PASSENGER SIDE OF UNIT 2 CAUSING
SEVERE DAMAGE TO BOTH VEHICLES.
UNIT 1 WAS LEAVING THE DRIVEWAY OF 7076N STONE LAKE ROAD. UNIT 2 WAS GOING NORTH ON STONE LAKE ROAD. DUE TO ICY ROAD AND DRIVEWAY CONDITIONS UNIT 1 SLID PAST THE DRIVEWAY STRIKING THE PASSENGER SIDE OF UNIT 2 CAUSING
SEVERE DAMAGE TO BOTH VEHICLES.
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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 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
02/23/2016
132 - Date Notified 1456133 - Time Notified (Military Time)1511134 - Time Arrived (Military Time)
02/23/2016
135 - Date Of Report
16022302169 16022303 19 - Special Study
18 - Agency Space
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MV4000e 01/2005
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