20160824 Zintak JennessAgency Accident Number
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Reportable Accident On Emergency Amended GZDWFRD
DOT Document Number Document Override Number
16082404
16
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8
2
4
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08/24/2016
4 - Accident Date
1518
5 - Time of Accident (Military Time)
02
6 - Total Units 7 - Total Injured 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
B16 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
13767W
17 - Structure Number
45.996646
12 - Latitude -91.38297513 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event REAR TO REAR93 - 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 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
EAST
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
IL
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
ZINTAK
25 - Operator/Pedestrian Last Name
GEORGE
25 - First Name
A
25 - Middle Initial 25 - Suffix
03/18
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
OAK FOREST
27 - City
IL
27 - State
60452
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
BACKING-MANEUVER
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
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZDWFRD 1 4
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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
CODGER2
56 - License Plate Number
AUT57 - Plate Type IL
58 - State
2017
59 - Exp Year
607
55 - Vehicle Identification Number
2008
50 - Year
CHEV
51 - Make
IMPALA
52 - Model
4D - 4DR
53 - Body Style
GLD
54 - Color 100 - Skidmarks to Impact (Ft)
REAR
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
ZINTAK
46 - Vehicle Owner Last Name
GEORGE
46 - First Name
A
46 - Middle Initial 46 - Suffix
03/18/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
OAK FOREST48 - City IL48 - State 6045248 - Zip Code (.49 - Telephone Number
TRAVELERS-CASUALTY-&-SURETY-CO63 - Liability Insurance Company Policy Holder Same As Owner60
ZINTAK
61 - Policy Holder Last Name
GEORGE
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
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
2018
31 - Expiration Year 34 - On Duty Accident
JENNESS
25 - Operator/Pedestrian Last Name
JOHN
25 - First Name 25 - Middle Initial 25 - Suffix
03/29/1
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 GZDWFRD 2 424
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Insurance
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26 - Address Street & Number 26 - PO Box
LADYSMITH
27 - City
WI
27 - State
54848
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
BACKING-MANEUVER
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
522RCS
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
6562
55 - Vehicle Identification Number
2003
50 - Year
CHEV
51 - Make
TRAILBLAZE
52 - Model
UT - SPORT UTILITY
53 - Body Style
DGR
54 - Color 100 - Skidmarks to Impact (Ft)
REAR
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
JENNESS
46 - Vehicle Owner Last Name
JOHN
46 - First Name 46 - Middle Initial 46 - Suffix
03/29/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
LADYSMITH48 - City WI48 - State 5484848 - Zip Code 49 - Telephone Number
AMERICAN-FAMILY63 - Liability Insurance Company Policy Holder Same As Owner60
JENNESS
61 - Policy Holder Last Name
JOHN
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZDWFRD 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
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
DEPUTY JEFF CAIN
UNIT ONE AND UNIT TWO WERE BOTH BACKING FROM THEIR RESPECTIVE PARKING SPACES AND COLLIDED IN THE TRAVEL LANE BETWEEN SPACESUNIT ONE AND UNIT TWO WERE BOTH BACKING FROM THEIR RESPECTIVE PARKING SPACES AND COLLIDED IN THE TRAVEL LANE BETWEEN SPACES
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125 - First Name 125 - Middle Initial
Officer Information
CAIN
125 - Officer Last Name
JEFF 314
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
08/24/2016
132 - Date Notified 1518133 - Time Notified (Military Time)1538134 - Time Arrived (Military Time)
08/29/2016
135 - Date Of Report
16082404 19 - Special Study
18 - Agency Space
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Wisconsin Motor Vehicle GZDWFRD 4 4