20161116 Loder Pringle NayquonabeAgency Accident Number
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Reportable Accident On Emergency Amended GZJ3QMC
DOT Document Number Document Override Number
16111606
16
1
1
1
6
0
6
11/16/2016
4 - Accident Date
1726
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 06, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
077
14 - On Hwy No.
EB
14 - On Street Name 14 - Bus/Frnt/Rmp
215 FT15 - Est. Distance EAST15 - Hwy. Dir
16 - Fr/At Hwy No.DUFFY RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.010256
12 - Latitude -91.45445313 - 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
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
ON-ROADWAY
117 - Relation To Roadway
DARK-LIGHTED114 - 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
4524 - 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
LODER
25 - Operator/Pedestrian Last Name
JULIE
25 - First Name
LORRAINE
25 - Middle Initial 25 - Suffix
11/16 FEMALE
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
STOPPED-IN-TRAFFIC
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.
OTHER
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
Page
PK2012
Wisconsin Motor Vehicle GZJ3QMC 1 5
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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
954TKS
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
71284
55 - Vehicle Identification Number
2012
50 - Year
DODG
51 - Make
G CARAVAN
52 - Model
VN - VAN
53 - Body Style
GRY
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
LODER
46 - Vehicle Owner Last Name
JULIE
46 - First Name
LORRAINE
46 - Middle Initial 46 - Suffix
11/16/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code (XT.49 - Telephone Number
STATE-FARM63 - Liability Insurance Company Policy Holder Same As Owner60
LODER
61 - Policy Holder Last Name
JULIE
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
EAST
23 - Dir Of Travel
4524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
P6521149484200
29 - Driver's License Number
WI
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
PRINGLE
25 - Operator/Pedestrian Last Name
CHELSEA
25 - First Name
NICOLE
25 - Middle Initial 25 - Suffix
09/FEMALE
33 - Sex
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZJ3QMC 2 525
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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 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
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
3
22 - Total Occupants
777VUZ
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
1276
55 - Vehicle Identification Number
2004
50 - Year
VOLK
51 - Make
BEETLE
52 - Model
2H - HATCHBACK 2
53 - Body Style
BLK
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT
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
NAYQUONABE
46 - Vehicle Owner Last Name
THELMA
46 - First Name
J
46 - Middle Initial 46 - Suffix
06/15
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
PROGRESSIVE63 - Liability Insurance Company Policy Holder Same As Owner60
NAYQUONABE
61 - Policy Holder Last Name
THELMA
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZJ3QMC 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
Occupant
Address Same As Operator
OC
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02
65 - Unit No
QUADERER
66 - Occupant Last Name
DEVIAH
66 - First Name
R
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
HAYWARD
68 - City
WI
68 - State
54843
68 - Zip Code
06/09/
67 - Date of Birth
F
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-APPLICABLE
75 - Ejected
Medical Transport
77
NOT-APPLICABLE
76 - Trapped/Extricated 78 - Agency Space
Occupant
Address Same As Operator
OC
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02
65 - Unit No
PRICE
66 - Occupant Last Name
BRAYLON
66 - First Name
J
66 - Middle Initial 66 - Suffix
02
68 - Address Street & Number 68 - PO Box
HAYWARD
68 - City
WI
68 - State
54843
68 - Zip Code
04/19/
67 - Date of Birth
M
69 - Sex
SECOND-SEAT-RIGHT
71 - Seat Position
CHILD-SAFETY-SEAT-USED
72 - Safety Equipment
N - NO APPARENT INJURY
70 - Injury Severity
NOT APPLICABLE
73 - Airbag
NOT-APPLICABLE
75 - Ejected
Medical Transport
77
NOT-APPLICABLE
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
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Wisconsin Motor Vehicle GZJ3QMC 4 5
105 - Photos By
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Diagram and Narrative
WHILE ON ROUTINE PATROL, I WAS DISPATCHED TO A TWO VEHICLE PROPERTY DAMAGE ACCIDENT AT THE INTERSECTION OF
DUFFY ROAD AND STATE HIGHWAY 77. WHILE IN ROUTE TO THE SCENE, DISPATCH ADVISED THAT THE VEHICLES HAD BEEN
MOVED TO 15148W STATE HIGHWAY 77. I ARRIVED ON SCENE. AFTER COLLECTING THE INFORMATION FROM BOTH DRIVERS, AND
INSTRUCTING THEM TO EXCHANGE NAMES, PHONE NUMBERS, AND TELEPHONE NUMBERS, I TALKED WITH THE OPERATOR OF UNIT 1. UNIT 1 ADVISED THAT SHE HAD SLOWED FOR A DEER CROSSING HIGHWAY 77 AND WAS STRUCK IN THE REAR BY UNIT 2.
UNIT 2 CONFIRMED THIS, AND STATED SHE DIDN'T SEE UNIT 1 UNTIL IT WAS TOO LATE. UNIT 2 REQUESTED A TOW DUE TO
RADIATOR DAMAGE. A SUPPLEMENTAL REPORT WILL BE ON FILE.
WHILE ON ROUTINE PATROL, I WAS DISPATCHED TO A TWO VEHICLE PROPERTY DAMAGE ACCIDENT AT THE INTERSECTION OF
DUFFY ROAD AND STATE HIGHWAY 77. WHILE IN ROUTE TO THE SCENE, DISPATCH ADVISED THAT THE VEHICLES HAD BEEN
MOVED TO 15148W STATE HIGHWAY 77. I ARRIVED ON SCENE. AFTER COLLECTING THE INFORMATION FROM BOTH DRIVERS, AND
INSTRUCTING THEM TO EXCHANGE NAMES, PHONE NUMBERS, AND TELEPHONE NUMBERS, I TALKED WITH THE OPERATOR OF UNIT 1. UNIT 1 ADVISED THAT SHE HAD SLOWED FOR A DEER CROSSING HIGHWAY 77 AND WAS STRUCK IN THE REAR BY UNIT 2.
UNIT 2 CONFIRMED THIS, AND STATED SHE DIDN'T SEE UNIT 1 UNTIL IT WAS TOO LATE. UNIT 2 REQUESTED A TOW DUE TO
RADIATOR DAMAGE. A SUPPLEMENTAL REPORT WILL BE ON FILE.
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125 - First Name 125 - Middle Initial
Officer Information
FREY
125 - Officer Last Name
NATHAN 397
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
11/16/2016
132 - Date Notified 1726133 - Time Notified (Military Time)1733134 - Time Arrived (Military Time)
11/16/2016
135 - Date Of Report
16111606 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZJ3QMC 5 5