20161017 BoushonAgency Accident Number
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Reportable Accident On Emergency Amended GZDFCJ6
DOT Document Number Document Override Number
10/17/2016
4 - Accident Date
0836
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County WINTER - 17, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
W
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
973 FT15 - Est. Distance SOUTH15 - Hwy. Dir
16 - Fr/At Hwy No.WEST LN16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.767304
12 - Latitude -90.76011413 - Longitude
GUARDRAIL END80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - 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
OUTSIDE-SHOULDER-RIGHT
117 - Relation To Roadway
DAYLIGHT114 - Light Condition DRY116 - Road Surface Condition FOG-SMOG-SMOKE118 - 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
1610171405579 - E M S Number
Operator/Pedestrian
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Unit Status
OVERTURN
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
2018
31 - Expiration Year 34 - On Duty Accident
BOUSHON
25 - Operator/Pedestrian Last Name
CHRISTINE
25 - First Name
M
25 - Middle Initial 25 - Suffix
11/19/
32 - Date Of Birth
FEMALE
33 - Sex
26 - Address Street & Number 26 - PO Box
PHILLIPS
27 - City
WI
27 - State
54555
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 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.
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
Accident Report
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Wisconsin Motor Vehicle GZDFCJ6 1 4
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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
643TDM
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
7648
55 - Vehicle Identification Number
2007
50 - Year
CHEV
51 - Make
TRAILBLAZE
52 - Model
UT - SPORT UTILITY
53 - Body Style
BLU
54 - Color 100 - Skidmarks to Impact (Ft)
TOTAL (DAMAGE TO ALL AREAS)
94 - Vehicle Damage
SEVERE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
WARGA AUTO & TRUCK CENTER
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
BOUSHON
46 - Vehicle Owner Last Name
CHRISTINE
46 - First Name
M
46 - Middle Initial 46 - Suffix
11/19/1
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
PHILLIPS48 - City WI48 - State 5455548 - Zip Code .49 - Telephone Number
WILSON-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
BOUSHON
61 - Policy Holder Last Name
CHRISTINE
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
Trailer
01
TR
L
106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
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Wisconsin Motor Vehicle GZDFCJ6 2 424
Fixed Objects Struck
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Property
GOVERNMENT
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
SAWYER COUNTY HIGHWAY DEPARTMENT
84 - Company Name
COUNTY/MUNICIPAL
Government Property Type
14688W CTH B
85 - Address Street & Number 85 - PO Box
HAYWARD
86 - City
WI
86 - State
54843
86 - Zip Code
(715) 634-2691 EXT.
87 - Telephone Number
NONE
83 - Government Damage Tag Number
01
82 - Striking Unit
GUARDRAIL-END
82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
105 - Photos By
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Diagram and Narrative
DEPUTY MATT JEFSON
ON MONDAY OCTOBER 17TH, 2016, I, DEPUTY MATTHEW JEFSON WAS DISPATCHED TO CTH W NEAR THE FLAMBEAU RIVER
BRIDGE FOR A ONE VEHICLE ROLL OVER WITH INJURY. WHILE EN ROUTE DISPATCH ADVISED THAT THE FEMALE DRIVER WHO
WAS THE ONLY OCCUPANT WAS OUT OF THE VEHICLE AND AT THE RANGER STATION AT 1613W CTH W WITH A POSSIBLE HEAD
INJURY. SOUTH MEDIC AND THE AMBULANCE CREW ARRIVED SHORTLY BEFORE I DID. WHEN I ARRIVED I SPOKE TO THE DRIVER
WHO STATED THAT SHE SWERVED TO MISS THREE DEER IN THE ROAD AND THEN HIT THE GUARD RAIL WHERE HER VEHICLE
THEN FLIPPED END OVER END AND LANDED IN THE FLAMBEAU RIVER. THE FEMALES HUSBAND ARRIVED SHORTLY BEFORE THE AMBULANCE TOOK THE FEMALE TO PARK FALLS. I ASKED HIM WHAT INSURANCE THEY HAD AND HE SAID WILSON MUTUAL
INSURANCE. I ASKED HIM WHERE HE WANTED THE VEHICLE TOWED TO AND IF HE PREFERRED A CERTAIN TOW SERVICE AND HE
STATED WARGA OUT OF PHILLIPS AND THAT THEY COULD JUST TAKE IT TO THERE SHOP. I ADVISED DISPATCH TO CONTACT
WARGA TO GET THEM EN ROUTE. I THEN WENT TO THE SCENCE WHERE I SAW A SUV IN THE RIVER JUST OFF SHORE ON ITS
WHEELS. I THEN WENT TO THE BEGINNING OF WHERE SHE HAD CRASHED AND NOTICED DAMAGE TO 5 POSTS AND 4 12' STEEL
GUARD RAILS. I THEN NOTICED TO BIG DIVOTS IN THE GROUND WHERE HER FRONT AND REAR PORTIONS OF THE VEHICLE HAD HIT. I THEN TOOK PHOTOS OF THE CRASH AND THE DAMAGE TO THE VEHICLE. WARGA ARRIVED ON SCENE. DEPUTY HOENE AND I
CONTROLLED TRAFFIC WHILE THEY REMOVED THE VEHICLE. THE VEHICLE WAS THEN LOADED AND TAKEN TO WARGA IN
PHILLIPS. I THEN CLEARED.
ON MONDAY OCTOBER 17TH, 2016, I, DEPUTY MATTHEW JEFSON WAS DISPATCHED TO CTH W NEAR THE FLAMBEAU RIVER
BRIDGE FOR A ONE VEHICLE ROLL OVER WITH INJURY. WHILE EN ROUTE DISPATCH ADVISED THAT THE FEMALE DRIVER WHO
WAS THE ONLY OCCUPANT WAS OUT OF THE VEHICLE AND AT THE RANGER STATION AT 1613W CTH W WITH A POSSIBLE HEAD
INJURY. SOUTH MEDIC AND THE AMBULANCE CREW ARRIVED SHORTLY BEFORE I DID. WHEN I ARRIVED I SPOKE TO THE DRIVER
WHO STATED THAT SHE SWERVED TO MISS THREE DEER IN THE ROAD AND THEN HIT THE GUARD RAIL WHERE HER VEHICLE
THEN FLIPPED END OVER END AND LANDED IN THE FLAMBEAU RIVER. THE FEMALES HUSBAND ARRIVED SHORTLY BEFORE THE AMBULANCE TOOK THE FEMALE TO PARK FALLS. I ASKED HIM WHAT INSURANCE THEY HAD AND HE SAID WILSON MUTUAL
INSURANCE. I ASKED HIM WHERE HE WANTED THE VEHICLE TOWED TO AND IF HE PREFERRED A CERTAIN TOW SERVICE AND HE
STATED WARGA OUT OF PHILLIPS AND THAT THEY COULD JUST TAKE IT TO THERE SHOP. I ADVISED DISPATCH TO CONTACT
WARGA TO GET THEM EN ROUTE. I THEN WENT TO THE SCENCE WHERE I SAW A SUV IN THE RIVER JUST OFF SHORE ON ITS
WHEELS. I THEN WENT TO THE BEGINNING OF WHERE SHE HAD CRASHED AND NOTICED DAMAGE TO 5 POSTS AND 4 12' STEEL
GUARD RAILS. I THEN NOTICED TO BIG DIVOTS IN THE GROUND WHERE HER FRONT AND REAR PORTIONS OF THE VEHICLE HAD HIT. I THEN TOOK PHOTOS OF THE CRASH AND THE DAMAGE TO THE VEHICLE. WARGA ARRIVED ON SCENE. DEPUTY HOENE AND I
CONTROLLED TRAFFIC WHILE THEY REMOVED THE VEHICLE. THE VEHICLE WAS THEN LOADED AND TAKEN TO WARGA IN
PHILLIPS. I THEN CLEARED.
Accident Report
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Wisconsin Motor Vehicle GZDFCJ6 3 4
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125 - First Name 125 - Middle Initial
Officer Information
JEFSON
125 - Officer Last Name
MATTHEW 324
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
10/17/2016
132 - Date Notified 0836133 - Time Notified (Military Time)0901134 - Time Arrived (Military Time)
10/26/2016
135 - Date Of Report
19 - Special Study
18 - Agency Space
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDFCJ6 4 4