20160815 Sheflin ArmstrongAgency Accident Number
AC
C
I
D
E
N
T
#
PO
L
I
C
E
#
Police Number
GE
N
E
R
A
L
I
N
F
O
R
M
A
T
I
O
N
Reportable Accident On Emergency Amended GZDWFRB
DOT Document Number Document Override Number
16081502
16
0
8
1
5
0
2
08/15/2016
4 - Accident Date
1250
5 - Time of Accident (Military Time)
02
6 - Total Units
02
7 - Total Injured 8 - Total Killed
SAWYER - 572 - County COUDERAY - 02, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
027
14 - On Hwy No.
NB
14 - On Street Name 14 - Bus/Frnt/Rmp
0.61 MI15 - Est. Distance NORTH15 - Hwy. Dir
16 - Fr/At Hwy No.WIEGOR RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.779031
12 - Latitude -91.27752013 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event REAR-END93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
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
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
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
CO
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
SHEFLIN
25 - Operator/Pedestrian Last Name
JOHN
25 - First Name
R
25 - Middle Initial 25 - Suffix
01/06/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
FORT COLLINS
27 - City
CO
27 - State
80526
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
B - NON-INCAPACITATING 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 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 UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFRB 1 5
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
2
22 - Total Occupants
CMX6419
56 - License Plate Number
AUT57 - Plate Type MI
58 - State
2017
59 - Exp Year
3N1CE2CP2GL36
55 - Vehicle Identification Number
2016
50 - Year
NISS
51 - Make
VERSA
52 - Model
4D - 4DR
53 - Body Style
WHI
54 - Color 100 - Skidmarks to Impact (Ft)
REAR, REAR DRIVER SIDE
94 - Vehicle Damage
SEVERE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
ROADRUNNER TOWING
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
46 - Vehicle Owner Last Name 46 - First Name 46 - Middle Initial 46 - Suffix Date Of Birth
RENTAL CAR FINANCE CORP46 - Company Name
47- Address Street & Number 47 - PO Box
DETROIT48 - City MI48 - State 48242-120248 - Zip Code 49 - Telephone Number
COUNTRY-PREFERRED-INSURANCE-CO63 - Liability Insurance Company Policy Holder Same As Owner60
SHEFLIN
61 - Policy Holder Last Name
JOHN
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
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
2017
31 - Expiration Year 34 - On Duty Accident
ARMSTRONG
25 - Operator/Pedestrian Last Name
KYLIE
25 - First Name
C
25 - Middle Initial 25 - Suffix
01/19/
32 - Date Of Birth
FEMALE
33 - Sex
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFRB 2 525
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
IN
S
26 - Address Street & Number 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
C - POSSIBLE 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
NEGOTIATING-CURVE
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.
FOLLOWING-TOO-CLOSE
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond UNKNOWN
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
1
22 - Total Occupants
464YSY
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
5GADT13S3421
55 - Vehicle Identification Number
2004
50 - Year
BUIC
51 - Make
RAINIER
52 - Model
UT - SPORT UTILITY
53 - Body Style
SIL
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT PASSENGER SIDE
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
A-1 TOWING
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
MILLER
46 - Vehicle Owner Last Name
CORY
46 - First Name
L
46 - Middle Initial 46 - Suffix
12/13
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
RADISSON48 - City WI48 - State 5486748 - Zip Code .49 - Telephone Number
PROGRESSIVE-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
MILLER
61 - Policy Holder Last Name
CORY
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFRB 3 5
School Bus
02
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Occupant
Address Same As Operator
OC
C
U
P
A
N
T
01
65 - Unit No
SHEFLIN
66 - Occupant Last Name
JOHNNY
66 - First Name 66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
FORT COLLINS
68 - City
CO
68 - State
80526
68 - Zip Code
10/30/
67 - Date of Birth
M
69 - Sex
FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER)
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
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
106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
105 - Photos By
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
DEPUTY JEFF CAIN
UNIT ONE WAS TRAVELING NORTH ON HWY 27/70 AND SLOWING TO TURN LEFT INTO A PRIVATE DRIVEWAY WHEN UNIT TWO,
TRAVELING IN THE SAME DIRECTION AND SAME LANE, DROVE INTO THE BACK OF UNIT 1.
UNIT ONE WAS TRAVELING NORTH ON HWY 27/70 AND SLOWING TO TURN LEFT INTO A PRIVATE DRIVEWAY WHEN UNIT TWO,
TRAVELING IN THE SAME DIRECTION AND SAME LANE, DROVE INTO THE BACK OF UNIT 1.
Officer Information
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFRB 4 5
OF
F
I
C
E
R
I
N
F
O
R
M
A
T
I
O
N
125 - First Name 125 - Middle Initial
CAIN
125 - Officer Last Name
JEFF 314
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
08/15/2016
132 - Date Notified 1250133 - Time Notified (Military Time)1306134 - Time Arrived (Military Time)
08/17/2016
135 - Date Of Report
16081502 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFRB 5 5