20160818 Leahy BerghAgency Accident Number
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Reportable Accident On Emergency Amended GZGXX63
DOT Document Number Document Override Number
16081811132
16
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8
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16081806
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08/18/2016
4 - Accident Date
1632
5 - Time of Accident (Military Time)
02
6 - Total Units
01
7 - Total Injured
01
8 - Total Killed
SAWYER - 572 - County LENROOT - 08, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
NELSON LAKE RD
14 - On Street Name 14 - Bus/Frnt/Rmp
537 FT15 - Est. Distance NORTH15 - Hwy. Dir
06316 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.070454
12 - Latitude -91.43254213 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event HEAD ON93 - 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
1608181113279 - E M S Number
Operator/Pedestrian
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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
WI
30 - State
2019
31 - Expiration Year 34 - On Duty Accident
LEAHY
25 - Operator/Pedestrian Last Name
MATTHEW
25 - First Name
JAMES
25 - Middle Initial 25 - Suffix
09/04/
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
C - POSSIBLE 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
NEGOTIATING-CURVE
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.
INATTENTIVE-DRIVING, LEFT-OF-CENTER
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
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Wisconsin Motor Vehicle GZGXX63 1 5
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
890WNJ
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
2G4WS52M0X1
55 - Vehicle Identification Number
1999
50 - Year
BUIC
51 - Make
CENTURY
52 - Model
4D - 4DR
53 - Body Style
TAN
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT PASSENGER SIDE, FRONT DRIVER SIDE
94 - Vehicle Damage
VERY-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
LEAHY
46 - Vehicle Owner Last Name
MATTHEW
46 - First Name
JAMES
46 - Middle Initial 46 - Suffix
09/04/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code .49 - Telephone Number
SENTRY-CASUALTY-CO63 - Liability Insurance Company Policy Holder Same As Owner60
LEAHY
61 - Policy Holder Last Name
MATTHEW
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
2020
31 - Expiration Year 34 - On Duty Accident
BERGH
25 - Operator/Pedestrian Last Name
ROBERT
25 - First Name
C
25 - Middle Initial 25 - Suffix
10/16/
32 - Date Of Birth
MALE
33 - Sex
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZGXX63 2 525
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Insurance
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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
K - FATAL INJURY
38 - Injury Severity
DEPLOYED
41 - Airbag
NOT-EJECTED
42 - Ejected 44
Medical Transport
TRAPPED/EXTRICATED
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.
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
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
G0TRD0N
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
1ZVHT88S1851 0
55 - Vehicle Identification Number
2008
50 - Year
FORD
51 - Make
MUSTANG
52 - Model
2D - 2DR
53 - Body Style
BLK
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT DRIVER SIDE, FRONT PASSENGER SIDE
94 - Vehicle Damage
VERY-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
BERGH
46 - Vehicle Owner Last Name
ROBERT
46 - First Name
C
46 - Middle Initial 46 - Suffix
10/16
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code .49 - Telephone Number
UNKNOWN63 - Liability Insurance Company Policy Holder Same As Owner60
BERGH
61 - Policy Holder Last Name
ROBERT
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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Wisconsin Motor Vehicle GZGXX63 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
POPLIN
UNIT 1 WAS GOING SOUTH ON NELSON LAKE RD AND UNIT 2 WAS GOING NORTH ON NELSON LAKE RD. BOTH UNITS WERE NEGOTIATING THE SAME CORNER IN OPPOSITE DIRECTIONS. THE DRIVER OF UNIT 1 SAID HE TOOK HIS EYES OFF OF THE ROAD
WHILE HE WAS PUTTING HIS INSURANCE PAPERS IN HIS GLOVE BOX. THE DRIVER OF UNIT 1 SAID HE WAS OVER THE CENTER
LINE IN THE WRONG LANE CAUSING THE CRASH. THE DRIVER OF UNIT 2 SAID UNIT 1 WAS IN HIS LANE WHEN THEY CAME AROUND
THE CORNER. DUE TO UNIT 1 BEING IN THE WRONG LANE BOTH UNITS HIT HEAD ON CAUSING SEVERE DAMAGE TO BOTH UNITS,
AND POSSIBLE INJURIES TO THE DRIVER OF UNIT 1. AT THE TIME OF THE CRASH THE DRIVER OF UNIT 2 WAS TALKING FINE AND
NOT COMPLAINING OF ANY SERIOUS INJURIES AND OPERATING HIS CELL PHONE TO TALK TO FAMILY. HOWEVER THE DRIVER OF UNIT 2 DID STATE HE NEED HELP OUT OF THE VEHICLE AND WAS TRAPPED AND HE NEEDED TO GO TO THE HOSPITAL. I LEARNED
LATER THAT THE DRIVER OF UNIT 2 SUCCUMBED TO HIS INJURIES AT THE HOSPITAL. UNIT 2 HAS APEX INSURANCE HOWEVER
THIS IS NOT A CHOICE ON THE MV4000 FORM. BOTH OPERATORS SAID THEY WERE WEARING THEIR SEAT BELT AT THE TIME OF
THE CRASH AND AIRBAGS DEPLOYED IN BOTH VEHICLES.
UNIT 1 WAS GOING SOUTH ON NELSON LAKE RD AND UNIT 2 WAS GOING NORTH ON NELSON LAKE RD. BOTH UNITS WERE NEGOTIATING THE SAME CORNER IN OPPOSITE DIRECTIONS. THE DRIVER OF UNIT 1 SAID HE TOOK HIS EYES OFF OF THE ROAD
WHILE HE WAS PUTTING HIS INSURANCE PAPERS IN HIS GLOVE BOX. THE DRIVER OF UNIT 1 SAID HE WAS OVER THE CENTER
LINE IN THE WRONG LANE CAUSING THE CRASH. THE DRIVER OF UNIT 2 SAID UNIT 1 WAS IN HIS LANE WHEN THEY CAME AROUND
THE CORNER. DUE TO UNIT 1 BEING IN THE WRONG LANE BOTH UNITS HIT HEAD ON CAUSING SEVERE DAMAGE TO BOTH UNITS,
AND POSSIBLE INJURIES TO THE DRIVER OF UNIT 1. AT THE TIME OF THE CRASH THE DRIVER OF UNIT 2 WAS TALKING FINE AND
NOT COMPLAINING OF ANY SERIOUS INJURIES AND OPERATING HIS CELL PHONE TO TALK TO FAMILY. HOWEVER THE DRIVER OF UNIT 2 DID STATE HE NEED HELP OUT OF THE VEHICLE AND WAS TRAPPED AND HE NEEDED TO GO TO THE HOSPITAL. I LEARNED
LATER THAT THE DRIVER OF UNIT 2 SUCCUMBED TO HIS INJURIES AT THE HOSPITAL. UNIT 2 HAS APEX INSURANCE HOWEVER
THIS IS NOT A CHOICE ON THE MV4000 FORM. BOTH OPERATORS SAID THEY WERE WEARING THEIR SEAT BELT AT THE TIME OF
THE CRASH AND AIRBAGS DEPLOYED IN BOTH VEHICLES.
Officer Information
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125 - First Name 125 - Middle Initial
POPLIN
125 - Officer Last Name
JAY 352
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
08/18/2016
132 - Date Notified 1632133 - Time Notified (Military Time)1641134 - Time Arrived (Military Time)
08/18/2016
135 - Date Of Report
16081811132 16081806 19 - Special Study
18 - Agency Space
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Wisconsin Motor Vehicle GZGXX63 5 5