20161117 Jackson HollatzAgency Accident Number
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Reportable Accident On Emergency Amended GZHJPJ1
DOT Document Number Document Override Number
16111707
16
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7
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11/17/2016
4 - Accident Date
1555
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County WINTER - 55, VILLAGE3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
HAZEL AVE
14 - On Street Name 14 - Bus/Frnt/Rmp
157 FT15 - Est. Distance WEST15 - Hwy. Dir
16 - Fr/At Hwy No.CTH W16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.821560
12 - Latitude -91.01206313 - Longitude
PARKED MOTOR VEHICLE80 - First Harmful Event ANGLE93 - 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
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
OP
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L - LEGALLY PARKED
Unit Status
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With 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 30 - State 31 - Expiration Year 34 - On Duty Accident
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
32 - Date Of Birth 33 - Sex
26 - Address Street & Number 26 - PO Box
27 - City 27 - State 27 - Zip Code 28 - Telephone Number
39 - Seat Position
NOT-APPLICABLE-NONMOTORIST
40 - Safety Equipment
38 - Injury Severity
NOT APPLICABLE
41 - Airbag
NOT-APPLICABLE
42 - Ejected 44
Medical Transport
NOT-APPLICABLE
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
LEGALLY-PARKED
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
88 - Driver or Pedestrian Cond 89 - Substance Presence
90 - Alcohol Test 90 - Alcohol Content 91 - Drug Test
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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
GN8811
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
4315
55 - Vehicle Identification Number
2010
50 - Year
FORD
51 - Make
F150
52 - Model
PK - PICKUP
53 - Body Style
DBL
54 - Color 100 - Skidmarks to Impact (Ft)
MIDDLE DRIVER SIDE
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
JACKSON
46 - Vehicle Owner Last Name
LUANNE
46 - First Name
J
46 - Middle Initial 46 - Suffix
06/04
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
EAU CLAIRE48 - City WI48 - State 5470348 - Zip Code .49 - Telephone Number
NOT-REQUIRED63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 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
H - HIT AND RUN
Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
EAST
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
2017
31 - Expiration Year 34 - On Duty Accident
HOLLATZ
25 - Operator/Pedestrian Last Name
DANIEL
25 - First Name
F
25 - Middle Initial 25 - Suffix
03/12/1
32 - Date Of Birth
MALE
33 - Sex
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Vehicle
Vehicle Owner
Insurance
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26 - Address Street & Number 26 - PO Box
AUBURNDALE
27 - City
WI
27 - State
54412
27 - Zip Code
.
28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
RESTRAINT-USE-UNKNOWN
40 - Safety Equipment
N - NO APPARENT INJURY
38 - Injury Severity
UNKNOWN
41 - Airbag
UNKNOWN
42 - Ejected 44
Medical Transport
UNKNOWN
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
BACKING-MANEUVER
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.
UNSAFE-BACKING
122 - Driver Factors
NOT OBSERVED88 - 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
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
KS7378
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2017
59 - Exp Year
6436
55 - Vehicle Identification Number
2002
50 - Year
FORD
51 - Make
F350
52 - Model
PK - PICKUP
53 - Body Style
RED
54 - Color 100 - Skidmarks to Impact (Ft)
UNKNOWN
94 - Vehicle Damage
UNKNOWN
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
HOLLATZ
46 - Vehicle Owner Last Name
SHARON
46 - First Name
L
46 - Middle Initial 46 - Suffix
12/29
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
AUBURNDALE48 - City WI48 - State 5441248 - Zip Code 49 - Telephone Number
PROGRESSIVE-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
HOLLATZ
61 - Policy Holder Last Name
SHARON
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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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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01
65 - Unit No
JACKSON
66 - Occupant Last Name
LUANNE
66 - First Name
J
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
68 - City 68 - State 68 - Zip Code
06/04/1
67 - Date of Birth
F
69 - Sex
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
72 - Safety Equipment
N - NO APPARENT INJURY
70 - Injury Severity
NON-DEPLOYED
73 - Airbag
NOT-EJECTED
75 - Ejected
Medical Transport
77
NOT-TRAPPED
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
105 - Photos By
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Diagram and Narrative
N. RASCHKA
ON NOVEMBER 17, 2016 AT APPROXIMATELY 3:57 PM I, DEPUTY RASCHKA WAS REQUESTED TO CONTACT LUANNE JACKSON REF
BEING BACKED INTO ON HAZEL STREET IN FRONT OF THE WINTER CO-OP GROCERY STORE. JACKSON STATED THAT SHE WAS
SITTING IN HER TRUCK TALKING ON THE PHONE PARKED FACING EAST TOWARD MAIN ST ALONG
ON NOVEMBER 17, 2016 AT APPROXIMATELY 3:57 PM I, DEPUTY RASCHKA WAS REQUESTED TO CONTACT LUANNE JACKSON REF
BEING BACKED INTO ON HAZEL STREET IN FRONT OF THE WINTER CO-OP GROCERY STORE. JACKSON STATED THAT SHE WAS
SITTING IN HER TRUCK TALKING ON THE PHONE PARKED FACING EAST TOWARD MAIN ST ALONG
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THE WINTER WONDERLAND BUILDING WHEN A TRUCK THAT WAS PARKED ALONG THE CO-OP IN THE ANGLE PARKING BEGAN BACKING UP. SHE STATED SHE NOTICED THAT THE TRUCK WAS NOT BACKING UP TO THE RIGHT TO GO AROUND THE BLOCK LIKE
A VEHICLE SHOULD IN THE ANGLE PARKING, INSTEAD THE TRUCK BEGAN BACKING UP TO THE LEFT, CAUSING THE TRUCKS RIGHT
REAR-END BUMPER TO STRIKE JACKSONS LOWER PORTION OF THE DRIVERS SIDE FRONT DOOR TO BE HIT. JACKSON STATED IT
LEFT A DENT THE SIZE OF A DOLLAR BILL AND MINOR PAINT SCRAPES. JACKSON STATED SHE WAS NOT INJURED AND STATED
THAT SHE WAS HONKING THE HORN, TRYING TO GET THE DRIVERS ATTENTION BUT DID NOT BELIEVE THE DRIVER, WHICH SHE
DESCRIBED AS AN OLDER MALE, COULD HEAR IT. SHE STATED THERE WERE PEDESTRIANS WHO WITNESSED IT BUT DID NOT GET THE DRIVERS ATTENTION EITHER. SHE GATHERED THE LICENSE PLATE NUMBER OF KS7378. STATED HER PLATE WAS GN8811.
SHE STATED SHE HAD VALID INSURANCE TO STATE FARM. I ADVISED I WOULD COME AND TAKE PICTURES OF THE DAMAGE FOR
REPORTING PURPOSES. I THEN WAS ABLE TO LOCATE THE DRIVER OF THE RED TRUCK THAT BACKED INTO HER. HE IDENTIFIED
HIMSELF AS DANIEL F HOLLATZ. HE STATED THAT HE WAS AT WINTER CO-OP ON NOV. 17 AROUND 4PM GETTING FOOD FOR THE
UPCOMING DEER OPENER. HE STATED HE DID NOT REALIZE HE HIT ANOTHER CAR AND DID NOT HEAR ANYONE HONKING. HE
STATED "I'M HALF DEAF ANYWAYS." HE STATED THAT HAD HE KNOWN HE HAD HIT ANOTHER VEHICLE, HE WOULD HAVE MOST
DEFINITELY STOPPED. I GATHERED HIS INSURANCE INFO WHICH WAS THROUGH PROGRESSIVE. THERE WAS NO DAMAGE TO HIS VEHICLE. I PROVIDED JACKSON WITH HOLLATZ'S INFORMATION. END OF REPORT.
THE WINTER WONDERLAND BUILDING WHEN A TRUCK THAT WAS PARKED ALONG THE CO-OP IN THE ANGLE PARKING BEGAN BACKING UP. SHE STATED SHE NOTICED THAT THE TRUCK WAS NOT BACKING UP TO THE RIGHT TO GO AROUND THE BLOCK LIKE
A VEHICLE SHOULD IN THE ANGLE PARKING, INSTEAD THE TRUCK BEGAN BACKING UP TO THE LEFT, CAUSING THE TRUCKS RIGHT
REAR-END BUMPER TO STRIKE JACKSONS LOWER PORTION OF THE DRIVERS SIDE FRONT DOOR TO BE HIT. JACKSON STATED IT
LEFT A DENT THE SIZE OF A DOLLAR BILL AND MINOR PAINT SCRAPES. JACKSON STATED SHE WAS NOT INJURED AND STATED
THAT SHE WAS HONKING THE HORN, TRYING TO GET THE DRIVERS ATTENTION BUT DID NOT BELIEVE THE DRIVER, WHICH SHE
DESCRIBED AS AN OLDER MALE, COULD HEAR IT. SHE STATED THERE WERE PEDESTRIANS WHO WITNESSED IT BUT DID NOT GET THE DRIVERS ATTENTION EITHER. SHE GATHERED THE LICENSE PLATE NUMBER OF KS7378. STATED HER PLATE WAS GN8811.
SHE STATED SHE HAD VALID INSURANCE TO STATE FARM. I ADVISED I WOULD COME AND TAKE PICTURES OF THE DAMAGE FOR
REPORTING PURPOSES. I THEN WAS ABLE TO LOCATE THE DRIVER OF THE RED TRUCK THAT BACKED INTO HER. HE IDENTIFIED
HIMSELF AS DANIEL F HOLLATZ. HE STATED THAT HE WAS AT WINTER CO-OP ON NOV. 17 AROUND 4PM GETTING FOOD FOR THE
UPCOMING DEER OPENER. HE STATED HE DID NOT REALIZE HE HIT ANOTHER CAR AND DID NOT HEAR ANYONE HONKING. HE
STATED "I'M HALF DEAF ANYWAYS." HE STATED THAT HAD HE KNOWN HE HAD HIT ANOTHER VEHICLE, HE WOULD HAVE MOST
DEFINITELY STOPPED. I GATHERED HIS INSURANCE INFO WHICH WAS THROUGH PROGRESSIVE. THERE WAS NO DAMAGE TO HIS VEHICLE. I PROVIDED JACKSON WITH HOLLATZ'S INFORMATION. END OF REPORT.
OF
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125 - First Name 125 - Middle Initial
Officer Information
RASCHKA
125 - Officer Last Name
NICOLE 388
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
11/17/2016
132 - Date Notified 1557133 - Time Notified (Military Time)1557134 - Time Arrived (Military Time)
11/17/2016
135 - Date Of Report
16111707 19 - Special Study
18 - Agency Space
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