20160512 Bolen WellsAgency Accident Number
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Reportable Accident On Emergency Amended GZDC4VB
DOT Document Number Document Override Number
16051205
16
0
5
1
2
0
5
05/12/2016
4 - Accident Date
1044
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County LENROOT - 08, TOWN3 - 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.MOSQUITO BROOK RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.085530
12 - Latitude -91.39583913 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event ANGLE93 - Manner of Collision
PARTIAL 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 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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A
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P
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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
2016
31 - Expiration Year 34 - On Duty Accident
BOLEN
25 - Operator/Pedestrian Last Name
MATTHEW
25 - First Name
J
25 - Middle Initial 25 - Suffix
06/09/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
CABLE
27 - City
WI
27 - State
54821
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 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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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDC4VB 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
LK0WEN7
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
5923
55 - Vehicle Identification Number
2009
50 - Year
DODG
51 - Make
RAM 1500
52 - Model
TK - TRUCK
53 - Body Style
TAN
54 - Color
0100 - Skidmarks to Impact (Ft)
REAR DRIVER SIDE
94 - Vehicle Damage
MINOR
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
BOLEN
46 - Vehicle Owner Last Name
JAMES
46 - First Name
D
46 - Middle Initial 46 - Suffix
06/19/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
CABLE48 - City WI48 - State 5482148 - Zip Code 49 - Telephone Number
ARMED-FORCES-INS-EXCHANGE63 - Liability Insurance Company Policy Holder Same As Owner60
BOLEN
61 - Policy Holder Last Name
JAMES
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
4524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2023
31 - Expiration Year 34 - On Duty Accident
WELLS
25 - Operator/Pedestrian Last Name
MICHAEL
25 - First Name
R
25 - Middle Initial 25 - Suffix
02/09/
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
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PK2012
Wisconsin Motor Vehicle GZDC4VB 2 424
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Vehicle
Vehicle Owner
Insurance
OP
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IN
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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
STOP-SIGN
120 - Traffic Control 162 - No. of Citations Issued
346.37(1)(C)3
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
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
KD8017
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2017
59 - Exp Year
3566
55 - Vehicle Identification Number
2010
50 - Year
DODG
51 - Make
DAKOTA SXT
52 - Model
TK - TRUCK
53 - Body Style
GRY
54 - Color
0100 - Skidmarks to Impact (Ft)
FRONT
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
WELLS
46 - Vehicle Owner Last Name
MICHAEL
46 - First Name
R
46 - Middle Initial 46 - Suffix
02/09
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
BADGER-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
WELLS
61 - Policy Holder Last Name
MICHAEL
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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Wisconsin Motor Vehicle GZDC4VB 3 4
School Bus
02
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
105 - Photos By
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Diagram and Narrative
DEPUTY DENNIS NELSON
ON MAY 12, 2016 DEPUTY SIMPSON RESPONDED TO HWY 63 AND MOSQUITO BROOKE FOR A TWO VEHICLE ACCIDENT. UNIT 1 WAS WAS NORTH BOUND ON HWY 63. UNIT 2 WAS ATTEMPTING TO CROSS HWY 63 FROM TO TRAVEL EAST ON MOSQUITO BROOKE.
UNIT 2 IMPACTED THE REAR DRIVER'S PORTION OF UNIT ONE CAUSING MINOR DAMAGE AND A FLAT TIRE TO UNIT 1. UNIT 2
SUSTAINED MINOR DAMAGE TO FRONT BUMPER PORTION.
ON MAY 12, 2016 DEPUTY SIMPSON RESPONDED TO HWY 63 AND MOSQUITO BROOKE FOR A TWO VEHICLE ACCIDENT. UNIT 1 WAS WAS NORTH BOUND ON HWY 63. UNIT 2 WAS ATTEMPTING TO CROSS HWY 63 FROM TO TRAVEL EAST ON MOSQUITO BROOKE.
UNIT 2 IMPACTED THE REAR DRIVER'S PORTION OF UNIT ONE CAUSING MINOR DAMAGE AND A FLAT TIRE TO UNIT 1. UNIT 2
SUSTAINED MINOR DAMAGE TO FRONT BUMPER PORTION.
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125 - First Name 125 - Middle Initial
Officer Information
SIMPSON125 - Officer Last Name MICHAEL 357131 - Officer ID
129 - Law Enforcement Agency No.
SAWYER COUNTY SHERIFFS DEPT
130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4858 EXT.
128 - Telephone Number
05/12/2016132 - Date Notified 1044133 - Time Notified (Military Time)1116134 - Time Arrived (Military Time)05/12/2016135 - Date Of Report
16051205 19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDC4VB 4 4