20160707 Thakkar MannAgency Accident Number
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Reportable Accident On Emergency Amended GZH0DMF
DOT Document Number Document Override Number
16070705
16
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7
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7
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16070705
16
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7
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07/07/2016
4 - Accident Date
1715
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 PARKING LOT11 - Accident Location
14 - On Hwy No.
PARKING LOT
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
2716 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
9966N
17 - Structure Number 12 - Latitude 13 - Longitude
PARKED MOTOR VEHICLE80 - 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
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
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Unit Status
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With
SOUTH
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
WI
30 - State
2021
31 - Expiration Year 34 - On Duty Accident
THAKKAR
25 - Operator/Pedestrian Last Name
JAYENDRA
25 - First Name
R
25 - Middle Initial 25 - Suffix
12/21/
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
RESTRAINT-USE-UNKNOWN
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
BACKING-MANEUVER
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.
UNSAFE-BACKING
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
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Accident Report
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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
199UEG
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
18995
55 - Vehicle Identification Number
2006
50 - Year
MERC
51 - Make
MONTEGO
52 - Model
4D - 4DR
53 - Body Style
SIL
54 - Color 100 - Skidmarks to Impact (Ft)
NONE
94 - Vehicle Damage
NONE
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
THAKKAR
46 - Vehicle Owner Last Name
JAYENDRA
46 - First Name
R
46 - Middle Initial 46 - Suffix
12/21/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
ALLSTATE63 - Liability Insurance Company Policy Holder Same As Owner60
THAKKAR
61 - Policy Holder Last Name
JAYENDRA
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
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With 23 - Dir Of Travel
N/A24 - Speed Limit
M 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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Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZH0DMF 2 525
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Vehicle
Vehicle Owner
Insurance
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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
MOTORCYCLE
21 - Unit Type
MOTORCYCLE
Vehicle Type
0
22 - Total Occupants
442BX
56 - License Plate Number
CYC57 - Plate Type WI
58 - State
2018
59 - Exp Year
2424
55 - Vehicle Identification Number
2015
50 - Year
HD
51 - Make
ULTRA LIMI
52 - Model
MC - MOTORCYCLE
53 - Body Style
BLK
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT 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
MANN
46 - Vehicle Owner Last Name
JOHN
46 - First Name
P
46 - Middle Initial
JR
46 - Suffix
04/11 1
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
SHAWANO48 - City WI48 - State 5416648 - 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
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Wisconsin Motor Vehicle GZH0DMF 3 5
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
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
SGT NICK ALMOGHRABI
I, SGT. NICK AL-MOGHRABI, WAS DISPATCHED TO THE NORTHERN PINE INN ON 07/07/16 FOR A PROPERTY DAMAGE CRASH. UPON ARRIVAL, I MET WITH THE OPERATORS ONE OF WHO WAS A MOTEL GUEST AND THE OTHER THE MOTEL OWNER. THE MOTEL
OWNER, JAYENDRA THAKKAR, WAS OPERATING HIS 2006 MERCURY SEDAN MARKED AS UNIT 1 IN REVERSE FROM THE MOTEL
UNIT PARKING STALL #10 WHEN HE BACKED INTO A 2015 HARLEY DAVIDSON OWNED BY JOHN MANN. THAKKAR STATED THAT HE
WASN'T PAYING ATTENTION AND FORGOT THE MOTORCYCLE WAS PARKED BEHIND HIM NEAR THE ENTRANCE TO THE MOTEL
OFFICE. MANN WAS NOT ON THE MOTORCYCLE AT THE TIME OF THE COLLISION. THERE WAS MINOR DAMAGE TO THE
MOTORCYCLE INCLUDING A SCRATCHES AND A DENT ON THE FRONT FENDER, SCRATCHES ON THE LEFT SIDE RADIATOR COVER, AND A BENT CRASH BAR. NO DAMAGE WAS SUSTAINED TO THAKKAR'S VEHICLE. BOTH SUBJECTS WERE PROVIDED WITH
DRIVER'S EXCHANGE OF INFORMATION AND WERE ADVISED TO CONTACT THEIR INSURANCE COMPANIES BOTH OF WHICH WERE
ALLSTATE. NO CITATIONS WERE ISSUED IN THIS MATTER.
I, SGT. NICK AL-MOGHRABI, WAS DISPATCHED TO THE NORTHERN PINE INN ON 07/07/16 FOR A PROPERTY DAMAGE CRASH. UPON ARRIVAL, I MET WITH THE OPERATORS ONE OF WHO WAS A MOTEL GUEST AND THE OTHER THE MOTEL OWNER. THE MOTEL
OWNER, JAYENDRA THAKKAR, WAS OPERATING HIS 2006 MERCURY SEDAN MARKED AS UNIT 1 IN REVERSE FROM THE MOTEL
UNIT PARKING STALL #10 WHEN HE BACKED INTO A 2015 HARLEY DAVIDSON OWNED BY JOHN MANN. THAKKAR STATED THAT HE
WASN'T PAYING ATTENTION AND FORGOT THE MOTORCYCLE WAS PARKED BEHIND HIM NEAR THE ENTRANCE TO THE MOTEL
OFFICE. MANN WAS NOT ON THE MOTORCYCLE AT THE TIME OF THE COLLISION. THERE WAS MINOR DAMAGE TO THE
MOTORCYCLE INCLUDING A SCRATCHES AND A DENT ON THE FRONT FENDER, SCRATCHES ON THE LEFT SIDE RADIATOR COVER, AND A BENT CRASH BAR. NO DAMAGE WAS SUSTAINED TO THAKKAR'S VEHICLE. BOTH SUBJECTS WERE PROVIDED WITH
DRIVER'S EXCHANGE OF INFORMATION AND WERE ADVISED TO CONTACT THEIR INSURANCE COMPANIES BOTH OF WHICH WERE
ALLSTATE. NO CITATIONS WERE ISSUED IN THIS MATTER.
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125 - First Name 125 - Middle Initial
Officer Information
ALMOGHRABI
125 - Officer Last Name
NICK 392
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
07/07/2016
132 - Date Notified 1719133 - Time Notified (Military Time)1729134 - Time Arrived (Military Time)
07/07/2016
135 - Date Of Report
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Wisconsin Motor Vehicle GZH0DMF 4 5
16070705 16070705 19 - Special Study
18 - Agency Space
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZH0DMF 5 5