HomeMy WebLinkAbout20150404 HexumAgency Accident Number
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Reportable Accident On Emergency Amended GZDPHZF
DOT Document Number Document Override Number
15040501
15
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4
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5
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04/04/2015
4 - Accident Date
2335
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County SAND LAKE - 14, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
E
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
475 FT15 - Est. Distance EAST15 - Hwy. Dir
16 - Fr/At Hwy No.WHITE FISH LAKE LN16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.863254
12 - Latitude -91.45515113 - Longitude
DITCH80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
DIVIDED-HIGHWAY-MEDIAN-STRIP-WITHOUT-TRAFFIC-BARRIER115 - Traffic Way
OFF-ROADWAY-LOCATION-UNKNOWN
117 - Relation To Roadway
DARK-NOT-LIGHTED114 - 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
1504040417379 - E M S Number
Operator/Pedestrian
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Unit Status
DITCH
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
2015
31 - Expiration Year 34 - On Duty Accident
HEXUM
25 - Operator/Pedestrian Last Name
ADAM
25 - First Name
A
25 - Middle Initial 25 - Suffix
12/06
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
STONE LAKE
27 - City
WI
27 - State
54876
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
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
346.63(1)(A)
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
OTHER
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond ALCOHOL-PRESENT
89 - Substance Presence
TEST REFUSED90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDPHZF 1 4
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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
UWTRAK
56 - License Plate Number
HEM57 - Plate Type WI
58 - State
2015
59 - Exp Year
4217
55 - Vehicle Identification Number
50 - Year
GM
51 - Make
TERRAIN
52 - Model
UT - SPORT UTILITY
53 - Body Style
WHI
54 - Color 100 - Skidmarks to Impact (Ft)
TOTAL (DAMAGE TO ALL AREAS)
94 - Vehicle Damage
SEVERE
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
HEXUM
46 - Vehicle Owner Last Name
ADAM
46 - First Name
A
46 - Middle Initial 46 - Suffix
12/06/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
STONE LAKE48 - City WI48 - State 5487648 - 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
01
01
01
01
BU
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FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Trailer
01
TR
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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
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZDPHZF 2 424
Fixed Objects Struck
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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
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
DEPUTY IAN HALL
VEHICLE WAS TRAVELING EAST ON COUNTY RD E. WHEN VEHICLE WENT AROUND CORNER IT WENT INTO THE DITCH AND ROLLED
MULTIPLE TIMES. THE VEHICLE CAME TO A STOP WITH ALL FOUR WHEELS IN THE AIR.
VEHICLE WAS TRAVELING EAST ON COUNTY RD E. WHEN VEHICLE WENT AROUND CORNER IT WENT INTO THE DITCH AND ROLLED
MULTIPLE TIMES. THE VEHICLE CAME TO A STOP WITH ALL FOUR WHEELS IN THE AIR.
Officer Information
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDPHZF 3 4
OF
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125 - First Name 125 - Middle Initial
GILLIS
125 - Officer Last Name
KEVIN 345
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
04/04/2015
132 - Date Notified 2337133 - Time Notified (Military Time)2359134 - Time Arrived (Military Time)
04/06/2015
135 - Date Of Report
15040501 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDPHZF 4 4