20160226 Anderson StormsAgency Accident Number
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Reportable Accident On Emergency Amended GZDJBDW
DOT Document Number Document Override Number
16022602
16
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2
2
6
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2
02/26/2016
4 - Accident Date
1020
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County SPIDER LAKE - 15, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
077
14 - On Hwy No.
EB
14 - On Street Name 14 - Bus/Frnt/Rmp
721 FT15 - Est. Distance EAST15 - Hwy. Dir
16 - Fr/At Hwy No.MURPHY BLVD16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
11332W
17 - Structure Number
46.070528
12 - Latitude -91.25550213 - 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
EAST
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
2022
31 - Expiration Year 34 - On Duty Accident
ANDERSON
25 - Operator/Pedestrian Last Name
MICHAEL
25 - First Name
S
25 - Middle Initial 25 - Suffix
06/18/1
32 - Date Of Birth
MALE
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
MAKING-LEFT-TURN
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
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
KX6372
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
2329
55 - Vehicle Identification Number
2004
50 - Year
GMC
51 - Make
K1500
52 - Model
TK - TRUCK
53 - Body Style
SIL
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT DRIVER SIDE
94 - Vehicle Damage
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
46 - Vehicle Owner Last Name 46 - First Name 46 - Middle Initial 46 - Suffix Date Of Birth
HAYWARD POWER SPORTS46 - Company Name
Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
MOTORISTS-COMMERCIAL-MUTUAL-INSURANCE-CO63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
HAYWARD POWER SPORTS61 - 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
5524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
MN
30 - State
2016
31 - Expiration Year 34 - On Duty Accident
STORMS
25 - Operator/Pedestrian Last Name
DOUGLAS
25 - First Name
D
25 - Middle Initial 25 - Suffix
12/30
32 - Date Of Birth
MALE
33 - Sex
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Wisconsin Motor Vehicle GZDJBDW 2 525
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Vehicle
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Insurance
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IN
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26 - Address Street & Number 26 - PO Box
LAKELAND
27 - City
MN
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
OVERTAKING-ON-LEFT
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
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
647GWG
56 - License Plate Number
AUT57 - Plate Type MN
58 - State
2016
59 - Exp Year
1760
55 - Vehicle Identification Number
2011
50 - Year
GMC
51 - Make
SIERRA
52 - Model
PK - PICKUP
53 - Body Style
BLU
54 - Color 100 - Skidmarks to Impact (Ft)
MIDDLE PASSENGER SIDE, FRONT 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
STORMS
46 - Vehicle Owner Last Name
DOUGLAS
46 - First Name
D
46 - Middle Initial 46 - Suffix
12/30/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
LAKELAND48 - City MN48 - State 5484348 - Zip Code 49 - Telephone Number
PROGRESSIVE-ADVANCED-INSURANCE-CO63 - Liability Insurance Company Policy Holder Same As Owner60
STORMS
61 - Policy Holder Last Name
DOUGLAS
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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1106 - 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
DENNIS NELSON
I, DEPUTY KNOOP RESPONDED WITH FIELD TRAINING OFFICER NELSON. UPON ARRIVING ON SCENE, I MET WITH ALL SUBJECTS. THE DRIVER OF UNIT 1 SAID THAT HE TURNED HIS RIGHT SIGNAL ON AND THEN TURNED IT OFF. HE THEN SAID THAT HE TURNED
HIS LEFT SIGNAL AND TURNED. HE THEN DROVE INTO UNIT 2. THE DRIVER OF UNIT 2 SAID THAT HE SAW UNIT 1 SIGNAL RIGHT
AND HE STARTED TO PASS IN THE LEFT LANE. THE LANE WAS A MARKED PASSING LANE. THE DRIVER OF UNIT 2 SAID THAT HE
WAS HIT BY UNIT 1 WHILE HE WAS PASSING. WOULD NOT VALIDATE WITH NO TRAILER OR TOWED NOT CHECKED. NO UNITS WERE
TOWED.
I, DEPUTY KNOOP RESPONDED WITH FIELD TRAINING OFFICER NELSON. UPON ARRIVING ON SCENE, I MET WITH ALL SUBJECTS. THE DRIVER OF UNIT 1 SAID THAT HE TURNED HIS RIGHT SIGNAL ON AND THEN TURNED IT OFF. HE THEN SAID THAT HE TURNED
HIS LEFT SIGNAL AND TURNED. HE THEN DROVE INTO UNIT 2. THE DRIVER OF UNIT 2 SAID THAT HE SAW UNIT 1 SIGNAL RIGHT
AND HE STARTED TO PASS IN THE LEFT LANE. THE LANE WAS A MARKED PASSING LANE. THE DRIVER OF UNIT 2 SAID THAT HE
WAS HIT BY UNIT 1 WHILE HE WAS PASSING. WOULD NOT VALIDATE WITH NO TRAILER OR TOWED NOT CHECKED. NO UNITS WERE
TOWED.
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Witness
KRAHN
107 - Witness Last Name
GERALD
107 - First Name
W
107 - Middle Initial
01
108 - Address Streeet & Number 108 - PO Box 2/17/109 - Date of Birth
HAYWARD
110 - City
WI
State
54843
110 - Zip Code
.
111 - Telephone Number
Officer Information
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125 - First Name 125 - Middle Initial
JENSEN
125 - Officer Last Name
DARIN 387
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
02/26/2016
132 - Date Notified 1022133 - Time Notified (Military Time)1026134 - Time Arrived (Military Time)
02/27/2016
135 - Date Of Report
16022602 19 - Special Study
18 - Agency Space
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