20161120 FarmsworthAgency Accident Number
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Police Number
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Reportable Accident On Emergency Amended GZDNRR1
DOT Document Number Document Override Number
16112002
16
1
1
2
0
0
2
11/20/2016
4 - Accident Date
1320
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County ROUND LAKE - 13, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
TWIN LAKE RD 6
14 - On Street Name 14 - Bus/Frnt/Rmp
77 FT15 - Est. Distance WEST15 - Hwy. Dir
16 - Fr/At Hwy No.BETHEL RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.041287
12 - Latitude -91.31733513 - Longitude
DITCH80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
HILL
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 ICE116 - Road Surface Condition CLOUDY118 - 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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P
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Unit Status
EMBANKMENT
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
2020
31 - Expiration Year 34 - On Duty Accident
FARMSWORTH
25 - Operator/Pedestrian Last Name
JEFFREY
25 - First Name
M
25 - Middle Initial 25 - Suffix
08/10
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
EAST TROY
27 - City
WI
27 - State
53120
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
01
Accident Report
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Page
PK2012
Wisconsin Motor Vehicle GZDNRR1 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
2
22 - Total Occupants
FQ2402
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
83
55 - Vehicle Identification Number
2005
50 - Year
DODG
51 - Make
RAM 1500
52 - Model
2D - 2DR
53 - Body Style
GRN
54 - Color
0100 - Skidmarks to Impact (Ft)
FRONT PASSENGER SIDE
94 - Vehicle Damage
MINOR
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
ROADRUNNER TOWING
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
FARMSWORTH
46 - Vehicle Owner Last Name
JEFFREY
46 - First Name
M
46 - Middle Initial 46 - Suffix
08/10
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
EAST TROY48 - City WI48 - State 5312048 - Zip Code 49 - Telephone Number
PROGRESSIVE-ADVANCED-INSURANCE-CO63 - Liability Insurance Company Policy Holder Same As Owner60
FARMSWORTH
61 - Policy Holder Last Name
JEFFREY
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
Occupant
Address Same As Operator
OC
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N
T
01
65 - Unit No
FARMSWORTH
66 - Occupant Last Name
CHARLENE
66 - First Name 66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
EAST TROY
68 - City
WI
68 - State
53120
68 - Zip Code
07/11/67 - Date of Birth F69 - Sex
FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER)
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
72 - Safety Equipment
Accident Report
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Wisconsin Motor Vehicle
Accident Report
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Wisconsin Motor Vehicle GZDNRR1 2 424
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
Fixed Objects Struck
PR
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N
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Property
UNKNOWN
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
84 - Company Name Government Property Type
85 - Address Street & Number 85 - PO Box
86 - City 86 - State 86 - Zip Code 87 - Telephone Number
83 - Government Damage Tag Number
01
82 - Striking Unit
TREE
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
DI
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Diagram and Narrative
DRIVER TOLD DEPUTY THAT THE DRIVER WAS TRAVELING STRAIGHT EAST BOUND ON ROADWAY. HIT ICE AND FISH TAILED INTO
THE DITCH. THE VEHICLE SLID INTO A TREE DAMAGING THE FRONT PASSENGER SIDE FENDER. DEPUTY OBSERVED THAT THE
ROADWAY WAS ICEY AT THE AREA IDENTIFIED BY DRIVER. DEPUTY CALLED TOWNSHIP MAINTENANCE AND THE ICE WAS TAKEN CARE OFF.
DRIVER TOLD DEPUTY THAT THE DRIVER WAS TRAVELING STRAIGHT EAST BOUND ON ROADWAY. HIT ICE AND FISH TAILED INTO
THE DITCH. THE VEHICLE SLID INTO A TREE DAMAGING THE FRONT PASSENGER SIDE FENDER. DEPUTY OBSERVED THAT THE
ROADWAY WAS ICEY AT THE AREA IDENTIFIED BY DRIVER. DEPUTY CALLED TOWNSHIP MAINTENANCE AND THE ICE WAS TAKEN CARE OFF.
Accident Report
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Wisconsin Motor Vehicle GZDNRR1 3 4
OF
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125 - First Name 125 - Middle Initial
Officer Information
SIMPSON
125 - Officer Last Name
MICHAEL 357
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
11/20/2016
132 - Date Notified 1320133 - Time Notified (Military Time)1328134 - Time Arrived (Military Time)
11/20/2016
135 - Date Of Report
16112002 19 - Special Study
18 - Agency Space
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDNRR1 4 4