20160506 Cloud, Hartnet, GroverAgency Accident Number
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Reportable Accident On Emergency Amended QRT43QP
DOT Document Number Document Override Number
16050605
16
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5
0
6
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05/06/2016
4 - Accident Date
1856
5 - Time of Accident (Military Time)
03
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 06, TOWN3 - Municipality PARKING LOT11 - Accident Location
14 - On Hwy No.
PARKING LOT
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
B16 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
13803W
17 - Structure Number
45.997098
12 - Latitude -91.38370913 - Longitude
PARKED MOTOR VEHICLE80 - 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
PARKING-LOT-OR-PRIVATE-PROPERTY115 - Traffic Way
PARKING-LOT-OR-PRIVATE-PROPERTY
117 - Relation To Roadway
DAYLIGHT114 - Light Condition DRY116 - 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
OP
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U - UNKNOWN
Unit Status
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With
EAST
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 30 - State 31 - Expiration Year 34 - On Duty Accident
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
32 - Date Of Birth 33 - Sex
26 - Address Street & Number 26 - PO Box
27 - City 27 - State 27 - Zip Code 28 - Telephone Number
39 - Seat Position
NONE-USED-VEHICLE-DRIVER/OCCUPANT
40 - Safety Equipment
38 - Injury Severity
NOT APPLICABLE
41 - Airbag
NOT-APPLICABLE
42 - Ejected 44
Medical Transport
NOT-APPLICABLE
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
NOT OBSERVED88 - 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
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PK2012
Wisconsin Motor Vehicle QRT43QP 1 6
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
2
22 - Total Occupants
4690AV
56 - License Plate Number
LTK57 - Plate Type TX
58 - State
2016
59 - Exp Year
23394
55 - Vehicle Identification Number
50 - Year
CHEV
51 - Make
VAN
52 - Model
VN - VAN
53 - Body Style
WHI
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE, FRONT
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OPERATOR
97 - Vehicle Removed By
BRAKE-SYSTEM
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
CLOUD
46 - Vehicle Owner Last Name
SYLVIA
46 - First Name
C
46 - Middle Initial 46 - Suffix
08/14/
46 - Company Name
47- Address Street & Number 47 - PO Box
KATY48 - City TX48 - State 77494-000048 - 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
01
01
01
01
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Operator/Pedestrian
L - LEGALLY PARKED
Unit Status
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With 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 30 - State 31 - Expiration Year 34 - On Duty Accident
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
32 - Date Of Birth 33 - Sex
Accident Report
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MV4000e 01/2005
Page
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Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle QRT43QP 2 626
VE
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Vehicle
Vehicle Owner
Insurance
OP
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A
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P
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IN
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26 - Address Street & Number 26 - PO Box
27 - City 27 - State 27 - Zip Code 28 - Telephone Number
39 - Seat Position
NOT-APPLICABLE-NONMOTORIST
40 - Safety Equipment
38 - Injury Severity
NOT APPLICABLE
41 - Airbag
NOT-APPLICABLE
42 - Ejected 44
Medical Transport
NOT-APPLICABLE
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
LEGALLY-PARKED
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
88 - Driver or Pedestrian Cond 89 - Substance Presence
90 - Alcohol Test 90 - Alcohol Content 91 - Drug Test
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
0
22 - Total Occupants
333SZE
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
31020
55 - Vehicle Identification Number
2014
50 - Year
FORD
51 - Make
ESCAPE
52 - Model
4D - 4DR
53 - Body Style
GRY
54 - Color 100 - 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
HARTNET
46 - Vehicle Owner Last Name
ROGER
46 - First Name
V
46 - Middle Initial 46 - Suffix
01/08/1
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 54843-640648 - 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
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Wisconsin Motor Vehicle QRT43QP 3 6
School Bus
02
BU
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FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
VE
H
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Operator/Pedestrian
Vehicle
Vehicle Owner
OP
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P
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A
N
L - LEGALLY PARKEDUnit Status PARKED MOTOR VEHICLE81 - Most Harmful Event: Collision With 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 30 - State 31 - Expiration Year 34 - On Duty Accident
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
32 - Date Of Birth 33 - Sex
26 - Address Street & Number 26 - PO Box
27 - City 27 - State 27 - Zip Code 28 - Telephone Number
39 - Seat Position
NOT-APPLICABLE-NONMOTORIST
40 - Safety Equipment
38 - Injury Severity NOT APPLICABLE41 - Airbag NOT-APPLICABLE42 - Ejected 44 Medical Transport
NOT-APPLICABLE
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
LEGALLY-PARKED119 - What Driver Was Doing NO-CONTROL120 - 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
88 - Driver or Pedestrian Cond 89 - Substance Presence
90 - Alcohol Test 90 - Alcohol Content 91 - Drug Test
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
0
22 - Total Occupants
846WHW56 - License Plate Number AUT57 - Plate Type WI58 - State 201659 - Exp Year 839955 - Vehicle Identification Number
2005
50 - Year
DODG
51 - Make
CARAVAN
52 - Model
VN - VAN
53 - Body Style
BLU
54 - Color 100 - Skidmarks to Impact (Ft)
REAR
94 - Vehicle Damage
MINOR
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OWNER
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
03
03
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Wisconsin Motor Vehicle QRT43QP 4 6
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Insurance
School Bus
IN
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45
Vehicle Owner Same As Operator
GROVER
46 - Vehicle Owner Last Name
DANIEL
46 - First Name
L
46 - Middle Initial 46 - Suffix
06/26
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD
48 - City
WI48 - State 54843
48 - Zip Code 49 - Telephone Number
NOT-REQUIRED
63 - Liability Insurance Company
Policy Holder Same As Owner
60
61 - Policy Holder Last Name 61 - Policy Holder First Name
61 - Policy Holder Company
03
03
03
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Occupant
Address Same As Operator
OC
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P
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N
T
01
65 - Unit No
CLOUD
66 - Occupant Last Name
WILLIAM
66 - First Name
D
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
68 - City 68 - State 68 - Zip Code
08/14/1
67 - Date of Birth
M
69 - Sex
TRAILING-UNIT-(TRAIN PASSENGER)
71 - Seat Position
NONE-USED-VEHICLE-DRIVER/OCCUPANT
72 - Safety Equipment
N - NO APPARENT INJURY
70 - Injury Severity
NON-DEPLOYED
73 - Airbag
NOT-EJECTED
75 - Ejected
Medical Transport
77
NOT-TRAPPED
76 - Trapped/Extricated 78 - Agency Space
Trailer
01
TR
L
1106 - Power Unit Number 5XT901License Plate Number RVTPlate Type TXState 2016Expiration Year
CHER
Trailer Make
RECR
Unit Type
04827
Vehicle Identification Number
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle QRT43QP 5 6
105 - Photos By
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Diagram and Narrative
UNIT 1 WAS PARKED IN PARKING LOT OF CASINO. OPERATOR OF UNIT 1 WAS IN CAMPER. OPERATOR STATES A GUST OF WIND
CAME UP AND HE FELT CAMPER MOVE. UNIT 1 ROLLED ACROSS PARKING LOT AND HIT UNIT 2 AND UNIT 3 WHICH WERE BOTH
LEGALLY PARKED IN PARKING LOT. OPERATOR OF UNIT 1 STATED HIS BRAKES FAILED WHICH CAUSED HIS CAMPER TO MOVE.
UNIT 1 WAS PARKED IN PARKING LOT OF CASINO. OPERATOR OF UNIT 1 WAS IN CAMPER. OPERATOR STATES A GUST OF WIND
CAME UP AND HE FELT CAMPER MOVE. UNIT 1 ROLLED ACROSS PARKING LOT AND HIT UNIT 2 AND UNIT 3 WHICH WERE BOTH
LEGALLY PARKED IN PARKING LOT. OPERATOR OF UNIT 1 STATED HIS BRAKES FAILED WHICH CAUSED HIS CAMPER TO MOVE.
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125 - First Name 125 - Middle Initial
Officer Information
ANDERSON
125 - Officer Last Name
SEAN 208
131 - Officer ID
129 - Law Enforcement Agency No.
TOWN OF HAYWARD POLICE DEPT
130 - Law Enforcement Agency Name
15460 W STH 77 / PO BOX 13260
126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4123 EXT.
128 - Telephone Number
05/06/2016
132 - Date Notified 1907133 - Time Notified (Military Time)1910134 - Time Arrived (Military Time)
05/06/2016
135 - Date Of Report
16050605 19 - Special Study
18 - Agency Space
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MV4000e 01/2005
Page
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Wisconsin Motor Vehicle QRT43QP 6 6