20160605 Chafer BennettAgency Accident Number
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Reportable Accident On Emergency Amended GZDSGVH
DOT Document Number Document Override Number
06/05/2016
4 - Accident Date
1740
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County RADISSON - 54, VILLAGE3 - Municipality NON-INTERSECTION11 - Accident Location
040
14 - On Hwy No.
SB
14 - On Street Name 14 - Bus/Frnt/Rmp
183 FT15 - Est. Distance SOUTH15 - Hwy. Dir
16 - Fr/At Hwy No.RAILROAD ST16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.768489
12 - Latitude -91.22121813 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event SIDESWIPE. SAME DIRECTION93 - 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
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Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
EAST
23 - Dir Of Travel
2524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
CHAFER
25 - Operator/Pedestrian Last Name
ROSE
25 - First Name
M
25 - Middle Initial 25 - Suffix
06/30/
32 - Date Of Birth
FEMALE
33 - Sex
26 - Address Street & Number
154
26 - PO Box
RADISSON
27 - City
WI
27 - State
54867
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-RIGHT-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 NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
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Wisconsin Motor Vehicle GZDSGVH 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
VISIBILITY-OBSCURED
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
393MAE
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
727
55 - Vehicle Identification Number
2006
50 - Year
CHEV
51 - Make
IMPALA LS
52 - Model
4D - 4DR
53 - Body Style
BLK
54 - Color
0100 - Skidmarks to Impact (Ft)
FRONT PASSENGER SIDE, 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
CHAFER
46 - Vehicle Owner Last Name
ROSE
46 - First Name
M
46 - Middle Initial 46 - Suffix
06/30
Date Of Birth
46 - Company Name
47- Address Street & Number
154
47 - PO Box
RADISSON48 - City WI48 - State 5486748 - Zip Code 49 - Telephone Number
ROCKFORD-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
CHAFER
61 - Policy Holder Last Name
ROSE
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
WEST
23 - Dir Of Travel
2524 - 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
BENNETT
25 - Operator/Pedestrian Last Name
JESSICA
25 - First Name
M
25 - Middle Initial 25 - Suffix
03/25/1
32 - Date Of Birth
FEMALE
33 - Sex
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Wisconsin Motor Vehicle
Accident Report
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Wisconsin Motor Vehicle GZDSGVH 2 424
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Insurance
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26 - PO Box
EXELAND
27 - City
WI
27 - State
54835
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 NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
91 - Drugs Reported
VISIBILITY-OBSCURED
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
MB1834
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2016
59 - Exp Year 55 - Vehicle Identification Number
1989
50 - Year
FORD
51 - Make
F150
52 - Model
2D - 2DR
53 - Body Style
BLK
54 - Color
0100 - Skidmarks to Impact (Ft)
FRONT, FRONT DRIVER SIDE
94 - Vehicle Damage
VERY-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
SMITH
46 - Vehicle Owner Last Name
DOMINIC
46 - First Name
M
46 - Middle Initial 46 - Suffix
11/09/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
CAMERON48 - City WI48 - State 54822-962848 - Zip Code 49 - Telephone Number
PROGRESSIVE-UNIVERSAL-INSURANCE-COMPANY63 - Liability Insurance Company Policy Holder Same As Owner60
SMITH
61 - Policy Holder Last Name
DOMINIC
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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Wisconsin Motor Vehicle GZDSGVH 3 4
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
ON JUNE 6, 2016 AT APPROXIMATELY 5:40PM, I, DEPUTY RYAN SCHICK RESPONDED TO A TWO VEHICLE ACCIDENT ON HWY 40 AT RAILROAD ST IN RADISSON. DISPATCH ADVISED NO INJURIES BUT LANE BLOCKAGE. I WITNESSED TWO VEHICLES IN THE
ROADWAY THAT HAD MINOR DAMAGE. I MADE CONTACT WITH EACH DRIVE, WHICH BOTH STATED A PICK-UP TRUCK WAS IN A
PARKING LOT WHERE THE INCIDENT OCCURRED OBSTRUCTING VISION OF THE ROADWAY. THE TRUCK WAS STILL ON SCENE AND
IT DID SLIGHTLY OBSTRUCT THE INTERSECTION. NO CITATIONS WERE ISSUED DUE TO THE FACT THERE WAS A TRUCK BLOCKING
THE INTERSECTION SLIGHTLY. SEE SWSO CASE NUMBER: 16060504 FOR MORE INFORMATION.
ON JUNE 6, 2016 AT APPROXIMATELY 5:40PM, I, DEPUTY RYAN SCHICK RESPONDED TO A TWO VEHICLE ACCIDENT ON HWY 40 AT RAILROAD ST IN RADISSON. DISPATCH ADVISED NO INJURIES BUT LANE BLOCKAGE. I WITNESSED TWO VEHICLES IN THE
ROADWAY THAT HAD MINOR DAMAGE. I MADE CONTACT WITH EACH DRIVE, WHICH BOTH STATED A PICK-UP TRUCK WAS IN A
PARKING LOT WHERE THE INCIDENT OCCURRED OBSTRUCTING VISION OF THE ROADWAY. THE TRUCK WAS STILL ON SCENE AND
IT DID SLIGHTLY OBSTRUCT THE INTERSECTION. NO CITATIONS WERE ISSUED DUE TO THE FACT THERE WAS A TRUCK BLOCKING
THE INTERSECTION SLIGHTLY. SEE SWSO CASE NUMBER: 16060504 FOR MORE INFORMATION.
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125 - First Name 125 - Middle Initial
Officer Information
SCHICK
125 - Officer Last Name
RYAN 351
131 - Officer ID
129 - Law Enforcement Agency No.SAWYER COUNTY SHERIFFS DEPT130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET
126 - Law Enforcement Agency Address Street & Number
HAYWARD127 - City WI127 - State 54843127 - Zip Code (715) 634-4858 EXT.128 - Telephone Number
06/05/2016
132 - Date Notified 1740133 - Time Notified (Military Time)1748134 - Time Arrived (Military Time)
06/16/2016
135 - Date Of Report
19 - Special Study
18 - Agency Space
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZDSGVH 4 4