HomeMy WebLinkAbout20150318 MillerAgency 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 GZDRQMD
DOT Document Number Document Override Number
15031703
15
0
3
1
7
0
3
15031703
15
0
3
1
7
0
3
03/18/2015
4 - Accident Date
1700
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 PARKING LOT11 - Accident Location
14 - On Hwy No.
PARKING LOT
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
02716 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
11128N
17 - Structure Number
46.036388
12 - Latitude -91.48807913 - Longitude
PARKED MOTOR VEHICLE80 - First Harmful Event UNKNOWN93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
PARKING-LOT-OR-PRIVATE-PROPERTY115 - Traffic Way
PARKING-LOT-OR-PRIVATE-PROPERTY
117 - Relation To Roadway
DAYLIGHT114 - Light Condition UNKNOWN116 - Road Surface Condition UNKNOWN118 - 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
L - LEGALLY PARKED
Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With 23 - Dir Of Travel
N/A24 - 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
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDRQMD 1 4
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
0
22 - Total Occupants
867TKY
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2015
59 - Exp Year
9521
55 - Vehicle Identification Number
2005
50 - Year
FORD
51 - Make
MUSTANG
52 - Model
2D - 2DR
53 - Body Style
GRN
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT
94 - Vehicle Damage
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
MILLER
46 - Vehicle Owner Last Name
DONALD
46 - First Name
P
46 - Middle Initial 46 - Suffix
03/11/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - 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
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With
WEST
23 - Dir Of Travel
N/A24 - 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
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDRQMD 2 424
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
27 - City 27 - State 27 - Zip Code 28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
RESTRAINT-USE-UNKNOWN
40 - Safety Equipment
38 - Injury Severity
UNKNOWN
41 - Airbag
UNKNOWN
42 - Ejected 44
Medical Transport
UNKNOWN
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
PARKING-MANEUVER
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.
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
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
56 - License Plate Number 57 - Plate Type WI
58 - State 59 - Exp Year 55 - Vehicle Identification Number
50 - Year 51 - Make 52 - Model 53 - Body Style 54 - Color
0100 - Skidmarks to Impact (Ft)
UNKNOWN
94 - Vehicle Damage
UNKNOWN
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
46 - Vehicle Owner Last Name 46 - First Name 46 - Middle Initial 46 - Suffix Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
48 - City 48 - State 48 - Zip Code 49 - Telephone Number
UNKNOWN63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDRQMD 3 4
School Bus
02
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
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
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
SGT GREG RIPCZINSKI
UNIT 1 WAS LEGALLLY PARKED AT 11128N IN THE NW CORNER OF THE LOT. AN UNKNOWN VEHICLE,, TRAVELING IN AN UNKNOWN MANNER, IS BELIEVED TO HAVE COLLIDED WITH UNIT 1 IN THE FRONT CENTER PORTION FOR THE FRONT END, CAUSING DAMAGE.UNIT 1 WAS LEGALLLY PARKED AT 11128N IN THE NW CORNER OF THE LOT. AN UNKNOWN VEHICLE,, TRAVELING IN AN UNKNOWN MANNER, IS BELIEVED TO HAVE COLLIDED WITH UNIT 1 IN THE FRONT CENTER PORTION FOR THE FRONT END, CAUSING DAMAGE.
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
RIPCZINSKI
125 - Officer Last Name
GREG 326
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
03/19/2015
132 - Date Notified 1722133 - Time Notified (Military Time)1811134 - Time Arrived (Military Time)
03/22/2015
135 - Date Of Report
15031703 15031703 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDRQMD 4 4