HomeMy WebLinkAbout20150117 Meyer Bolz MahoneyAgency Accident Number
AC
C
I
D
E
N
T
#
PO
L
I
C
E
#
Police Number
GE
N
E
R
A
L
I
N
F
O
R
M
A
T
I
O
N
Reportable Accident On Emergency Amended GZDVPJ1
DOT Document Number Document Override Number
15011700721
15
0
1
1
7
0
0
7
2
1
15011701
15
0
1
1
7
0
1
01/17/2015
4 - Accident Date
1159
5 - Time of Accident (Military Time)
03
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County LENROOT - 08, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
OO
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
782 FT15 - Est. Distance SOUTH15 - Hwy. Dir
16 - Fr/At Hwy No.JANET RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.110374
12 - Latitude -91.30457913 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event SIDESWIPE. OPPOSITE DIRECTION93 - 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 WET116 - 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
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
WEST
23 - Dir Of Travel
5524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
IL
30 - State
2016
31 - Expiration Year 34 - On Duty Accident
MEYER
25 - Operator/Pedestrian Last Name
STEVEN
25 - First Name
ERIC
25 - Middle Initial 25 - Suffix
11/30 MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
LINCOLNSHIRE
27 - City
IL
27 - State
60069
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
C - POSSIBLE 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
346.05(1)
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
LEFT-OF-CENTER, FAILURE-TO-HAVE-CONTROL, DRIVER-CONDITION
122 - Driver Factors
ABILITY IMPAIRED88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJ1 1 6
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
2
22 - Total Occupants
1893BK
56 - License Plate Number
AUT57 - Plate Type IL
58 - State
2015
59 - Exp Year
3829
55 - Vehicle Identification Number
2014
50 - Year
SUBA
51 - Make 52 - Model
SW - STATIONWAG
53 - Body Style
WHI
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT DRIVER SIDE, FRONT PASSENGER SIDE
94 - Vehicle Damage
SEVERE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
MEYER
46 - Vehicle Owner Last Name
STEVEN
46 - First Name
ERIC
46 - Middle Initial 46 - Suffix
11/30/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
LINCOLNSHIRE48 - City IL48 - State 6006948 - Zip Code . 49 - Telephone Number
COUNTRY-CASUALTY-INSURANCE-CO63 - Liability Insurance Company Policy Holder Same As Owner60
MEYER
61 - Policy Holder Last Name
STEVEN
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
5524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
MN
30 - State
2017
31 - Expiration Year 34 - On Duty Accident
BOLZ
25 - Operator/Pedestrian Last Name
JASON
25 - First Name 25 - Middle Initial 25 - Suffix
06/12/
32 - Date Of Birth
MALE
33 - Sex
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJ1 2 626
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
IN
S
26 - Address Street & Number 26 - PO Box
LAKE ELMO
27 - City
MN
27 - State
55042
27 - Zip Code
.
28 - Telephone Number
PEDESTRIAN-(NONOCCUPPANT)
39 - Seat Position
NONE-USED-VEHICLE-DRIVER/OCCUPANT
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
ILLEGALLY-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
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
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
323NXH
56 - License Plate Number
LTK57 - Plate Type MN
58 - State
2015
59 - Exp Year
828
55 - Vehicle Identification Number
2007
50 - Year
FORD
51 - Make 52 - Model
TK - TRUCK
53 - Body Style
GLD
54 - Color 100 - Skidmarks to Impact (Ft)
REAR, REAR DRIVER SIDE
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OWNER
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
BOLZ
46 - Vehicle Owner Last Name
JASON
46 - First Name
THOMAS
46 - Middle Initial 46 - Suffix
06/12/
Date Of Birth
46 - Company Name
Number 47 - PO Box
LAKE ELMO48 - City MN48 - State 5504248 - Zip Code 49 - Telephone Number
USAA-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
BOLZ
61 - Policy Holder Last Name
JASON
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJ1 3 6
School Bus
02
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
VE
H
I
C
L
E
Operator/Pedestrian
Vehicle
Vehicle Owner
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
Unit Status MOTOR VEHICLE IN TRANSPORT81 - Most Harmful Event: Collision With EAST23 - Dir Of Travel 5524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number WI30 - State 202131 - Expiration Year 34 - On Duty Accident
MAHONEY
25 - Operator/Pedestrian Last Name
KEVIN
25 - First Name 25 - Middle Initial 25 - Suffix
09/1432 - Date Of Birth MALE33 - Sex
26 - Address Street & Number 26 - PO Box
EAU CLAIRE27 - City WI27 - State 5470127 - Zip Code 28 - Telephone Number
PEDESTRIAN-(NONOCCUPPANT)
39 - Seat Position
NONE-USED-VEHICLE-DRIVER/OCCUPANT
40 - Safety Equipment
N - NO APPARENT INJURY38 - Injury Severity NON-DEPLOYED41 - Airbag NOT-EJECTED42 - Ejected 44 Medical Transport
NOT-TRAPPED
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
ILLEGALLY-PARKED119 - What Driver Was Doing NO-CONTROL120 - 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
NOT OBSERVED88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content
TEST NOT GIVEN
91 - Drug Test
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
FL176556 - License Plate Number LTK57 - Plate Type WI58 - State 201559 - Exp Year 6651355 - Vehicle Identification Number
2008
50 - Year
CHEV
51 - Make
SILVERADO
52 - Model
TK - TRUCK
53 - Body Style
GRY
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OWNER
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
03
03
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJ1 4 6
VE
H
O
W
N
E
R
Insurance
School Bus
IN
S
45
Vehicle Owner Same As Operator
MAHONEY
46 - Vehicle Owner Last Name
KEVIN
46 - First Name 46 - Middle Initial 46 - Suffix
09/14/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
EAU CLAIRE
48 - City
WI48 - State 54701
48 - Zip Code 49 - Telephone Number
UNKNOWN
63 - Liability Insurance Company
Policy Holder Same As Owner
60
61 - Policy Holder Last Name 61 - Policy Holder First Name
61 - Policy Holder Company
03
03
03
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Occupant
Address Same As Operator
OC
C
U
P
A
N
T
01
65 - Unit No
LUTZ
66 - Occupant Last Name
LINDA
66 - First Name
L
66 - Middle Initial 66 - Suffix
68 - Address Street & Number 68 - PO Box
LINCOLNSHIRE
68 - City
IL
68 - State
60069
68 - Zip Code
07/08/
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
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
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJ1 5 6
105 - Photos By
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
POPLIN
UNIT 2 AND 3 WERE BOTH PARKED PARTIALLY IN THE ROADWAY OF COUNTY HWY OO FACING EAST. UNIT 1 WAS GOING WEST ON
COUNTY HWY OO. THE DRIVER OF UNIT 1 ADVISED THAT HIS LEGS WENT NUMMB CAUSING HIM TO GO INTO THE DEEP SNOW ON
THE NORTH SHOULDER OF THE ROAD. THE DRIVER OF UNIT1 ADVISED THAT HE CORRECTED BACK ONTO THE ROADWAY AND
CROSSED THE ENTIRE ROAD STRIKING UNIT 2 AND 3 CAUSING THE DAMAGE. UNIT 2 AND 3 WERE UNOCCUPIED AT THE TIME OF
THE INCIDENT. THERE WAS ALSO A VERY LARGE CROSS COUNTRY SKI RACE GOING ON AT THIS TIME AND THERE WERE
APPROXIMATELY 100 CARS PARKED ON COUNTY HWY OO AND THE MAJORITY OF THEM WERE OVER THE FOG LINE AND IN THE ROADWAY.
UNIT 2 AND 3 WERE BOTH PARKED PARTIALLY IN THE ROADWAY OF COUNTY HWY OO FACING EAST. UNIT 1 WAS GOING WEST ON
COUNTY HWY OO. THE DRIVER OF UNIT 1 ADVISED THAT HIS LEGS WENT NUMMB CAUSING HIM TO GO INTO THE DEEP SNOW ON
THE NORTH SHOULDER OF THE ROAD. THE DRIVER OF UNIT1 ADVISED THAT HE CORRECTED BACK ONTO THE ROADWAY AND
CROSSED THE ENTIRE ROAD STRIKING UNIT 2 AND 3 CAUSING THE DAMAGE. UNIT 2 AND 3 WERE UNOCCUPIED AT THE TIME OF
THE INCIDENT. THERE WAS ALSO A VERY LARGE CROSS COUNTRY SKI RACE GOING ON AT THIS TIME AND THERE WERE
APPROXIMATELY 100 CARS PARKED ON COUNTY HWY OO AND THE MAJORITY OF THEM WERE OVER THE FOG LINE AND IN THE ROADWAY.
OF
F
I
C
E
R
I
N
F
O
R
M
A
T
I
O
N
125 - First Name 125 - Middle Initial
Officer Information
POPLIN
125 - Officer Last Name
JAY 352
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
01/17/2015
132 - Date Notified 1159133 - Time Notified (Military Time)1208134 - Time Arrived (Military Time)
01/17/2015
135 - Date Of Report
15011700721 15011701 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJ1 6 6