20161103 Blanchard MetcalfAgency Accident Number
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Reportable Accident On Emergency Amended GZHQM9F
DOT Document Number Document Override Number
11/03/2016
4 - Accident Date
1600
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 53, CITY3 - 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 BUSINESS16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
10514
17 - Structure Number 12 - Latitude 13 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event REAR-END93 - 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
NORTH
23 - Dir Of Travel
1524 - 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
BLANCHARD
25 - Operator/Pedestrian Last Name
SPENCER
25 - First Name
L
25 - Middle Initial 25 - Suffix
03/06/
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
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
SLOWING-OR-STOPPING
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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MV4000e 01/2005
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Wisconsin Motor Vehicle GZHQM9F 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
227FWN
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
97
55 - Vehicle Identification Number
2001
50 - Year
GMC
51 - Make
JIMMY
52 - Model
4H - HATCHBACK 4
53 - Body Style
RED
54 - Color
0100 - Skidmarks to Impact (Ft)
REAR, REAR PASSENGER SIDE, REAR DRIVER SIDE
94 - Vehicle Damage
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
BLANCHARD
46 - Vehicle Owner Last Name
KELLI
46 - First Name
B
46 - Middle Initial 46 - Suffix
07/18/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
WESTERN-NATIONAL-MUTUAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
BLANCHARD
61 - Policy Holder Last Name
KELLI
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
1524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
mber
WI
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
METCALF
25 - Operator/Pedestrian Last Name
COLTON
25 - First Name
E
25 - Middle Initial 25 - Suffix
01/12
32 - Date Of Birth
MALE
33 - Sex
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZHQM9F 2 424
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Vehicle
Vehicle Owner
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
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
GOING-STRAIGHT
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 162 - No. of Citations Issued
346.14(1)
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 NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
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
545XPB
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
34635
55 - Vehicle Identification Number
2004
50 - Year
PONT
51 - Make
GRAND PRIX
52 - Model
4D - 4DR
53 - Body Style
BLK
54 - Color
0100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE, FRONT, FRONT PASSENGER SIDE
94 - Vehicle Damage
MODERATE
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
METCALF
46 - Vehicle Owner Last Name
MACKENZIE
46 - First Name
L
46 - Middle Initial 46 - Suffix
06/16/1
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
GEICO-ADVANTAGE-INSURANCE-CO63 - Liability Insurance Company Policy Holder Same As Owner60
METCALF
61 - Policy Holder Last Name
MACKENZIE
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZHQM9F 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
CITY OF HAYWARD OFFICER CHARLIE LOGAN
PLEASE REFER TO SWSO CASE #:16110301PLEASE REFER TO SWSO CASE #:16110301
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125 - First Name 125 - Middle Initial
Officer Information
SCHICK
125 - Officer Last Name
RYAN 351
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
11/03/2016
132 - Date Notified 1600133 - Time Notified (Military Time)1601134 - Time Arrived (Military Time)
11/20/2016
135 - Date Of Report
19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZHQM9F 4 4