20160612 Kelsey KarstenAgency Accident Number
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Reportable Accident On Emergency Amended GZDJBDZ
DOT Document Number Document Override Number
16061207436
16
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6
1
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06/12/2016
4 - Accident Date
1548
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 06, TOWN3 - Municipality INTERSECTION11 - Accident Location
063
14 - On Hwy No.
EB
14 - On Street Name 14 - Bus/Frnt/Rmp
0 FT15 - Est. Distance 15 - Hwy. Dir
16 - Fr/At Hwy No.HOSPITAL ROAD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number 12 - Latitude 13 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event ANGLE93 - 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
WEST
23 - Dir Of Travel
3524 - 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
KELSEY
25 - Operator/Pedestrian Last Name
MICHAEL
25 - First Name
A
25 - Middle Initial 25 - Suffix
06/03/1960
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
GOING-STRAIGHT
119 - What Driver Was Doing
STOP-SIGN
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
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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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
804SMY
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
04
55 - Vehicle Identification Number
2015
50 - Year
JEEP
51 - Make
GRAND CHER
52 - Model
UT - SPORT UTILITY
53 - Body Style 54 - Color 100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE, FRONT
94 - Vehicle Damage
SEVERE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
KELSEY
46 - Vehicle Owner Last Name
MICHAEL
46 - First Name
A
46 - Middle Initial 46 - Suffix
06/03
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code .49 - Telephone Number
PEKIN-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
KELSEY
61 - Policy Holder Last Name
MICHAEL
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
SOUTH
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
2017
31 - Expiration Year 34 - On Duty Accident
KARSTEN
25 - Operator/Pedestrian Last Name
MICHELLE
25 - First Name
LYNN
25 - Middle Initial 25 - Suffix
11/08/
32 - Date Of Birth
FEMALE
33 - Sex
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Wisconsin Motor Vehicle GZDJBDZ 2 525
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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
MINNEAPOLIS
27 - City
MN
27 - State
55417
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
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 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
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
PASSENGER-CAR
Vehicle Type
2
22 - Total Occupants
814NZT
56 - License Plate Number
AUT57 - Plate Type MN
58 - State
2017
59 - Exp Year
249
55 - Vehicle Identification Number
2008
50 - Year
HOND
51 - Make
CRV
52 - Model
UT - SPORT UTILITY
53 - Body Style 54 - Color 100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE, FRONT
94 - Vehicle Damage
SEVERE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
KARSTEN
46 - Vehicle Owner Last Name
MICHELLE
46 - First Name
LYNN
46 - Middle Initial 46 - Suffix
11/08/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
MINNEAPOLIS48 - City MN48 - State 5541748 - Zip Code 49 - Telephone Number
USAA-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
KARSTEN
61 - Policy Holder Last Name
MICHELLE
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
Occupant
Address Same As Operator
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02
65 - Unit No
MATLOCK
66 - Occupant Last Name
OLIVER
66 - First Name
A
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
MINNEAPOLIS
68 - City
MN
68 - State
55417
68 - Zip Code
07/29/
67 - Date of Birth
M
69 - Sex
THIRD-ROW-LEFT-SIDE-(SIDECAR: MOTORCYCLE PASSENGER)
71 - Seat Position
CHILD-SAFETY-SEAT-USED
72 - Safety Equipment
N - NO APPARENT INJURY
70 - Injury Severity
NON-DEPLOYED
73 - Airbag
NOT-APPLICABLE
75 - Ejected
Medical Transport
77
NOT-APPLICABLE
76 - Trapped/Extricated 78 - Agency Space
Trailer
01
TR
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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
UNIT 1 WAS TRAVELING WEST ON HOSPITAL ROAD. UNIT 2 WAS TRAVELING SOUTH ON US HIGHWAY 63. UNIT 1 OPERATOR
STATED HE LOOKED BOTH WAYS AND STARTED TO PROCEED THROUGH THE INTERSECTION WHEN THE CRASH OCCURRED. UNIT
1 OPERATOR STATED HE DID NOT SEE THE VEHICLE WHEN HE LOOKED. UNIT 1 STRUCK UNIT
UNIT 1 WAS TRAVELING WEST ON HOSPITAL ROAD. UNIT 2 WAS TRAVELING SOUTH ON US HIGHWAY 63. UNIT 1 OPERATOR
STATED HE LOOKED BOTH WAYS AND STARTED TO PROCEED THROUGH THE INTERSECTION WHEN THE CRASH OCCURRED. UNIT
1 OPERATOR STATED HE DID NOT SEE THE VEHICLE WHEN HE LOOKED. UNIT 1 STRUCK UNIT
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2 IN THE FRONT DRIVER SIDE TIRE ARE OF THE VEHICLE.2 IN THE FRONT DRIVER SIDE TIRE ARE OF THE VEHICLE.
OF
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125 - First Name 125 - Middle Initial
Officer Information
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
06/12/2016
132 - Date Notified 1548133 - Time Notified (Military Time)1549134 - Time Arrived (Military Time)
06/12/2016
135 - Date Of Report
16061207436 19 - Special Study
18 - Agency Space
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