20160316 PobloskeAgency Accident Number
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Reportable Accident On Emergency Amended GZDT737
DOT Document Number Document Override Number
16031602
16
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3
1
6
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03/16/2016
4 - Accident Date
2134
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County ROUND LAKE - 13, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
MOOSE LAKE RD
14 - On Street Name 14 - Bus/Frnt/Rmp
0.48 MI15 - Est. Distance SOUTH15 - Hwy. Dir
16 - Fr/At Hwy No.LOUIES LANDING RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.023664
12 - Latitude -91.07226013 - Longitude
TREE80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
113 - Road Curvature
HILL
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
OUTSIDE-SHOULDER-RIGHT
117 - Relation To Roadway
DARK-NOT-LIGHTED114 - Light Condition SNOW/SLUSH116 - 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
TREE
81 - Most Harmful Event: Collision With
WEST
23 - Dir Of Travel
2024 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
IL
30 - State
2017
31 - Expiration Year 34 - On Duty Accident
POBLOSKE
25 - Operator/Pedestrian Last Name
CHARLES
25 - First Name
K
25 - Middle Initial
JR
25 - Suffix
06/20/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
SCHAUMBURG
27 - City
IL
27 - State
60194
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
NEGOTIATING-CURVE
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 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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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
E351325
56 - License Plate Number
AUT57 - Plate Type IL
58 - State
2016
59 - Exp Year
794
55 - Vehicle Identification Number
2004
50 - Year
HOND
51 - Make
CARRYALL
52 - Model
4H - HATCHBACK 4
53 - Body Style
GRY
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT PASSENGER SIDE, MIDDLE 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
POBLOSKE
46 - Vehicle Owner Last Name
CHARLES
46 - First Name
K
46 - Middle Initial
JR
46 - Suffix
06/20
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
SCHAUMBURG48 - City IL48 - State 6019448 - Zip Code .49 - Telephone Number
CINCINNATI-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
POBLOSKE
61 - Policy Holder Last Name
CHARLES
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
Trailer
01
TR
L
106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
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Wisconsin Motor Vehicle GZDT737 2 424
Fixed Objects Struck
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Property
UNKNOWN
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
84 - Company Name Government Property Type
85 - Address Street & Number 85 - PO Box
86 - City 86 - State 86 - Zip Code 87 - Telephone Number
83 - Government Damage Tag Number
01
82 - Striking Unit
TREE
82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
105 - Photos By
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Diagram and Narrative
DEPUTY MATTHEW JEFSON
ON WEDNESDAY MARCH 16TH, 2016, I, DEPUTY MATTHEW JEFSON OF THE SAWYER COUNTY SHERIFF'S DEPARTMENT WAS
DISPATCHED TO MOOSE LAKE RD APPROXIMATELY 1/2 MILE EAST OF LOUIE'S LANDING FOR A ONE VEHICLE CRASH. DISPATCH
ADVISED THAT ROADRUNNER HAD CALLED AND STATED THAT THEY WENT TO GET A VEHICLE OUT OF THE DITCH AND WHEN
THEY PULLED IT UP THEY REALIZED THAT THERE WAS WELL OVER A THOUSAND DOLLARS IN DAMAGE. I WENT EN ROUTE AND
ARRIVED ON SCENE AT APPROXIMATELY 22:02. ROADRUNNER ALREADY HAD THE VEHICLE OUT OF THE DITCH AND ON THE
ROADWAY. I SPOKE WITH THE DRIVER AND DID A RECORDS CHECK OF THE VEHICLE AND THE DRIVER BOTH WERE VALID. I ASKED THE DRIVER WHAT HAD HAPPENED AND HE STATED THAT HE CAME AROUND THE CORNER AND HIS FRONT PASSENGER TIRE
SLIDE OF THE ROAD AND THE VEHICLE GOT SUCKED INTO THE DITCH AND HIT SOME TREES. THE DRIVER DID HAVE CINCINNATI
INSURANCE. I TOOK PHOTOS OF THE DAMAGE TO THE VEHICLE AND THEY WILL BE TURNED INTO EVIDENCE UNDER THE CASE #
16031602. THE DRIVER STATED THAT HE WOULD JUST DRIVE THE VEHICLE TO HIS NEARBY CABIN. THERE WERE NO INJURIES AND
THE DRIVER WAS WEARING HIS SEATBELT. THE ROAD WAS COVERED WITH ICE AND SNOW FROM A RECENT SNOW STORM. I
CLEARED AT APPROXIMATELY 22:16. THIS IS ALL THE INFORMATION I HAVE AT THIS TIME.
ON WEDNESDAY MARCH 16TH, 2016, I, DEPUTY MATTHEW JEFSON OF THE SAWYER COUNTY SHERIFF'S DEPARTMENT WAS
DISPATCHED TO MOOSE LAKE RD APPROXIMATELY 1/2 MILE EAST OF LOUIE'S LANDING FOR A ONE VEHICLE CRASH. DISPATCH
ADVISED THAT ROADRUNNER HAD CALLED AND STATED THAT THEY WENT TO GET A VEHICLE OUT OF THE DITCH AND WHEN
THEY PULLED IT UP THEY REALIZED THAT THERE WAS WELL OVER A THOUSAND DOLLARS IN DAMAGE. I WENT EN ROUTE AND
ARRIVED ON SCENE AT APPROXIMATELY 22:02. ROADRUNNER ALREADY HAD THE VEHICLE OUT OF THE DITCH AND ON THE
ROADWAY. I SPOKE WITH THE DRIVER AND DID A RECORDS CHECK OF THE VEHICLE AND THE DRIVER BOTH WERE VALID. I ASKED THE DRIVER WHAT HAD HAPPENED AND HE STATED THAT HE CAME AROUND THE CORNER AND HIS FRONT PASSENGER TIRE
SLIDE OF THE ROAD AND THE VEHICLE GOT SUCKED INTO THE DITCH AND HIT SOME TREES. THE DRIVER DID HAVE CINCINNATI
INSURANCE. I TOOK PHOTOS OF THE DAMAGE TO THE VEHICLE AND THEY WILL BE TURNED INTO EVIDENCE UNDER THE CASE #
16031602. THE DRIVER STATED THAT HE WOULD JUST DRIVE THE VEHICLE TO HIS NEARBY CABIN. THERE WERE NO INJURIES AND
THE DRIVER WAS WEARING HIS SEATBELT. THE ROAD WAS COVERED WITH ICE AND SNOW FROM A RECENT SNOW STORM. I
CLEARED AT APPROXIMATELY 22:16. THIS IS ALL THE INFORMATION I HAVE AT THIS TIME.
Officer Information
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125 - First Name 125 - Middle Initial
JEFSON
125 - Officer Last Name
MATTHEW 324
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
03/16/2016
132 - Date Notified 2134133 - Time Notified (Military Time)2202134 - Time Arrived (Military Time)
03/25/2016
135 - Date Of Report
16031602 19 - Special Study
18 - Agency Space
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