20161211 TuckerAgency Accident Number
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Police Number
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Reportable Accident On Emergency Amended GZHZ99F
DOT Document Number Document Override Number
16121110
16
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16121110
16
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12/11/2016
4 - Accident Date
2030
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County LENROOT - 08, TOWN3 - Municipality INTERSECTION11 - Accident Location
14 - On Hwy No.
LARSEN RD
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
16 - Fr/At Hwy No.PFEIFER RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.099209
12 - Latitude -91.38548413 - Longitude
DITCH80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
PARTIAL 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
SHOULDER-(OTHER THAN SHOULDER WITHIN MEDIAN OR GORE)
117 - Relation To Roadway
DARK-NOT-LIGHTED114 - Light Condition SNOW/SLUSH116 - Road Surface Condition SNOW118 - 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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Unit Status
DITCH
81 - Most Harmful Event: Collision With
SOUTH
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
2021
31 - Expiration Year 34 - On Duty Accident
TUCKER
25 - Operator/Pedestrian Last Name
RUSSELL
25 - First Name
W
25 - Middle Initial 25 - Suffix
09/02/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
SPOONER
27 - City
WI
27 - State
54801
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
MAKING-RIGHT-TURN
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 0062 - 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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PK2012
Wisconsin Motor Vehicle GZHZ99F 1 5
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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
4
22 - Total Occupants
363YTX
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
42514
55 - Vehicle Identification Number
2006
50 - Year
TOYT
51 - Make
SIENNA
52 - Model
VN - VAN
53 - Body Style
WHI
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT DRIVER SIDE, FRONT, UNDERCARRIAGE
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
ENGEN
46 - Vehicle Owner Last Name
KIRA
46 - First Name
N
46 - Middle Initial 46 - Suffix
07/26 0
Date Of Birth
46 - Company Name
& Number 47 - PO Box
SPOONER48 - City WI48 - State 5480148 - Zip Code .49 - Telephone Number
PROGRESSIVE-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
ENGEN
61 - Policy Holder Last Name
KIRA
61 - Policy Holder First Name
61 - Policy Holder Company
01
01
01
01
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
ENGEN
66 - Occupant Last Name
KIRA
66 - First Name
N
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
SPOONER
68 - City
WI
68 - State
54801
68 - Zip Code
07/26/67 - Date of Birth F69 - Sex
SECOND-SEAT-MIDDLE
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
72 - Safety Equipment
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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Wisconsin Motor Vehicle GZHZ99F 2 525
N - NO APPARENT INJURY
70 - Injury Severity
NOT APPLICABLE
73 - Airbag
NOT-EJECTED
75 - Ejected
Medical Transport
77
NOT-TRAPPED
76 - Trapped/Extricated 78 - Agency Space
Occupant
Address Same As Operator
OC
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01
65 - Unit No
HUDSON
66 - Occupant Last Name
LOGAN
66 - First Name
S
66 - Middle Initial 66 - Suffix
02
68 - Address Street & Number 68 - PO Box
HAYWARD
68 - City
WI
68 - State
54843
68 - Zip Code
07/03/
67 - Date of Birth
M
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-EJECTED
75 - Ejected
Medical Transport
77
NOT-TRAPPED
76 - Trapped/Extricated 78 - Agency Space
Occupant
Address Same As Operator
OC
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P
A
N
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01
65 - Unit No
NICHOLS
66 - Occupant Last Name
ALEXANDRA
66 - First Name
J
66 - Middle Initial 66 - Suffix
03
68 - Address Street & Number 68 - PO Box
HAYWARD
68 - City
WI
68 - State
54843
68 - Zip Code
07/14/
67 - Date of Birth
F
69 - Sex
THIRD-ROW-MIDDLE
71 - Seat Position
NONE-USED-VEHICLE-DRIVER/OCCUPANT
72 - Safety Equipment
C - POSSIBLE INJURY
70 - Injury Severity
NOT APPLICABLE
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
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZHZ99F 3 5
Fixed Objects Struck
PR
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Property
GOVERNMENT
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
TOWN OF LENROOT
84 - Company Name
COUNTY/MUNICIPAL
Government Property Type
12215 N USH 63
85 - Address Street & Number 85 - PO Box
HAYWARD
86 - City
WI
86 - State
54843
86 - Zip Code 87 - Telephone Number
1
83 - Government Damage Tag Number
01
82 - Striking Unit
DITCH
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
ON 12/11/16, AT APPROXIMATELY 2124 HRS, I WAS SEND TO THE HAYWARD AREA HOSPITAL ER TO MEET WITH A FEMALE SUBJECT
WHO WAS THE PASSENGER IN A 1 VEHICLE CRASH THAT HAD OCCURRED AROUND 2030 HRS THAT EVENING AT THE
INTERSECTION OF LARSEN RD AND PFIEFER RD IN LENROOT TWSP. I SPOKE WITH THE FEMALE PASSENGER, THE MALE DRIVER,
AND THE OTHER TWO PASSENGERS THAT WERE IN THE VEHICLE. THE DRIVER OF UNIT 1 STATED THAT THEY WERE TRAVELING
SOUTH ON LARSEN RD AT APPROXIMATELY 15 MPH IN ORDER TO TURN RIGHT ONTO PFIEFER RD. HE STATED THE ROADS WERE
SLIPPERY ENOUGH THAT THEY SLID THROUGH THE INTERSECTION AND ENDED UP IN THE DITCH, CAUSING MODERATE DAMAGE TO THE FRONT DRIVER SIDE OF THE VEHICLE AND CAUSING POSSIBLE MINOR INJURIES TO ONE PASSENGER. HE STATED HE AND
THE OTHER MALE PASSENGER WERE ABLE TO GET THE VEHICLE OUT OF THE DITCH WHILE THE OWNER ATTEMPTED TO CALL
SAWYER COUNTY DISPATCH; HOWEVER SHE DID NOT HAVE CELL SERVICE. HE STATED ONCE THE VEHICLE WAS OUT, THEY
DROVE TO THE HOSPITAL TO HAVE THE PASSENGER SEEN IN THE ER.
ON 12/11/16, AT APPROXIMATELY 2124 HRS, I WAS SEND TO THE HAYWARD AREA HOSPITAL ER TO MEET WITH A FEMALE SUBJECT
WHO WAS THE PASSENGER IN A 1 VEHICLE CRASH THAT HAD OCCURRED AROUND 2030 HRS THAT EVENING AT THE
INTERSECTION OF LARSEN RD AND PFIEFER RD IN LENROOT TWSP. I SPOKE WITH THE FEMALE PASSENGER, THE MALE DRIVER,
AND THE OTHER TWO PASSENGERS THAT WERE IN THE VEHICLE. THE DRIVER OF UNIT 1 STATED THAT THEY WERE TRAVELING
SOUTH ON LARSEN RD AT APPROXIMATELY 15 MPH IN ORDER TO TURN RIGHT ONTO PFIEFER RD. HE STATED THE ROADS WERE
SLIPPERY ENOUGH THAT THEY SLID THROUGH THE INTERSECTION AND ENDED UP IN THE DITCH, CAUSING MODERATE DAMAGE TO THE FRONT DRIVER SIDE OF THE VEHICLE AND CAUSING POSSIBLE MINOR INJURIES TO ONE PASSENGER. HE STATED HE AND
THE OTHER MALE PASSENGER WERE ABLE TO GET THE VEHICLE OUT OF THE DITCH WHILE THE OWNER ATTEMPTED TO CALL
SAWYER COUNTY DISPATCH; HOWEVER SHE DID NOT HAVE CELL SERVICE. HE STATED ONCE THE VEHICLE WAS OUT, THEY
DROVE TO THE HOSPITAL TO HAVE THE PASSENGER SEEN IN THE ER.
Officer Information
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHZ99F 4 5
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125 - First Name 125 - Middle Initial
JOHNSON
125 - Officer Last Name
JEFF 322
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
12/11/2016
132 - Date Notified 2124133 - Time Notified (Military Time)2130134 - Time Arrived (Military Time)
12/12/2016
135 - Date Of Report
16121110 16121110 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHZ99F 5 5