HomeMy WebLinkAbout20150601 Waggoner PetitAgency Accident Number
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Reportable Accident On Emergency Amended GZDT72V
DOT Document Number Document Override Number
15060107090
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15060105
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06/01/2015
4 - Accident Date
1315
5 - Time of Accident (Military Time)
02
6 - Total Units 7 - Total Injured 8 - Total Killed
SAWYER - 572 - County HAYWARD - 06, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
HOSPITAL RD
14 - On Street Name 14 - Bus/Frnt/Rmp
243 FT15 - Est. Distance WEST15 - Hwy. Dir
06316 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.026964
12 - Latitude -91.46324513 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event REAR-END93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
LEVEL/FLAT
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 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 79 - E M S Number
Operator/Pedestrian
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Unit Status
MOTOR VEHICLE IN TRANSPORT
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
2016
31 - Expiration Year 34 - On Duty Accident
WAGGONER
25 - Operator/Pedestrian Last Name
RYAN
25 - First Name
M
25 - Middle Initial 25 - Suffix
03/13/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
MINONG
27 - City
WI
27 - State
54859
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
BACKING-MANEUVER
119 - What Driver Was Doing
STOP-SIGN
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
APPEARED NORMAL88 - Driver or Pedestrian Cond UNKNOWN
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 GZDT72V 1 5
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
AK2539
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2015
59 - Exp Year 55 - Vehicle Identification Number
2000
50 - Year
GMC
51 - Make
SIERRA
52 - Model
PK - PICKUP
53 - Body Style
GRY
54 - Color 100 - Skidmarks to Impact (Ft)
NONE
94 - Vehicle Damage
NONE
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
WAGGONER
46 - Vehicle Owner Last Name
JOHN
46 - First Name
R
46 - Middle Initial 46 - Suffix
03/14
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
MENOMONIE48 - City WI48 - State 5475148 - Zip Code 49 - Telephone Number
PROGRESSIVE-PREMIER-INS-CO-OF-ILLINOIS63 - Liability Insurance Company Policy Holder Same As Owner60
WAGGONER
61 - Policy Holder Last Name
JOHN
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
Operator/Pedestrian
Unit Status
MOTOR VEHICLE IN TRANSPORT
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
2017
31 - Expiration Year 34 - On Duty Accident
PETIT
25 - Operator/Pedestrian Last Name
JENNIFER
25 - First Name
L
25 - Middle Initial 25 - Suffix
07/06
32 - Date Of Birth
FEMALE
33 - Sex
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZDT72V 2 525
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Vehicle
Vehicle Owner
Insurance
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IN
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26 - Address Street & Number 26 - PO Box
HAYWARD
27 - City
WI
27 - State
54843
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
STOPPED-IN-TRAFFIC
119 - What Driver Was Doing
STOP-SIGN
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
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
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
2
22 - Total Occupants
260HWC
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
3 1155
55 - Vehicle Identification Number
2010
50 - Year
FORD
51 - Make
FUSION SEL
52 - Model
4D - 4DR
53 - Body Style
RED
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
PETIT
46 - Vehicle Owner Last Name
JENNIFER
46 - First Name
L
46 - Middle Initial 46 - Suffix
07/06/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
AMERICAN-FAMILY63 - Liability Insurance Company Policy Holder Same As Owner60
PETIT
61 - Policy Holder Last Name
JENNIFER
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
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Wisconsin Motor Vehicle GZDT72V 3 5
School Bus
02
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
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02
65 - Unit No
RICH
66 - Occupant Last Name 66 - First Name
L
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
HAYWARD
68 - City
WI
68 - State
54843
68 - Zip Code
01/25
67 - Date of Birth
F
69 - Sex
SECOND-SEAT-RIGHT
71 - Seat Position
CHILD-SAFETY-SEAT-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
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
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Diagram and Narrative
AMBER AL-MOGHRABI
ON JUNE 1, 2015 WHILE WORKING PATROL, I WAS DISPATCHED TO HWY 63 AND HOSPITAL ROAD FOR A REPORT OF A MINOR
ACCIDENT. UPON ARRIVAL AT 13:23, I WAS MET BY OFFICER CHARLIE LOGAN WITH THE CITY OF HAYWARD POLICE DEPARTMENT.
OFFICER LOGAN STATED HE ALREADY RAN BOTH PARTIES VEHICLE REGISTRATIONS THROUGH
ON JUNE 1, 2015 WHILE WORKING PATROL, I WAS DISPATCHED TO HWY 63 AND HOSPITAL ROAD FOR A REPORT OF A MINOR
ACCIDENT. UPON ARRIVAL AT 13:23, I WAS MET BY OFFICER CHARLIE LOGAN WITH THE CITY OF HAYWARD POLICE DEPARTMENT.
OFFICER LOGAN STATED HE ALREADY RAN BOTH PARTIES VEHICLE REGISTRATIONS THROUGH
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDT72V 4 5
DISPATCH AND HE JUST NEEDED TO GET THE INFORMATION ON WHAT HAPPENED. I ASKED BOTH PARTIES FOR THEIR DRIVERS LICENSES TO RUN THROUGH DISPATCH ALSO AND THEY BOTH CAME BACK VALID. I ASKED THE RYAN WHAT HAD HAPPENED. HE
STATED HE WAS STOPPED AT THE STOP SIGN ON HOSPITAL ROAD HEADED EAST AND JENNIFER WAS STOPPED BEHIND HIM. HE
STATED A LARGE TRUCK WAS TURNING WEST FROM HWY 63 ONTO HOSPITAL ROAD AND HE DIDNT THINK THERE WAS ENOUGH
ROOM SO HE BACKED UP TO GIVE THE TRUCK MORE ROOM. RYAN STATED WHEN HE LOOKED BACK BEFORE HE BACKED UP HE
DID NOT SEE JENNIFER'S VEHICLE BEHIND HIM. JENNIFER AGREED TO THE STORY. BOTH PARTIES STATED THEY WERE WEARING
THEIR SEATBELTS AND JENNIFER'S BABY IN THE BACK SEAT WAS BUCKLED INTO HER CARSEAT. I NOTICED A CRACKED DENT IN THE FRONT OF JENNIFERS FRONT BUMPER. UPON LOOKING AT THE REST OF THE VEHICLE IT DID NOT APPEAR TO HAVE
ANYMORE DAMAGE. UPON LOOKING AT RYAN'S VEHICLE IT DID NOT APPEAR TO HAVE ANY DAMAGE. IT APPEARED THE HITCH OF
HIS TRUCK HIT HER VEHICLE AND DENTED IT. I TOOK PICTURES OF THE DAMAGED PORTION OF JENNIFER'S VEHICLE AND
ENTERED THEM INTO EVIDENCE. RYAN AND JENNIFER EXCHANGED INFORMATION. I TOLD JENNIFER TO GET AN ESTIMATE ON
HER VEHICLE AND TO LET ME KNOW WHEN SHE GETS ONE. WE ALL CLEARED THE CALL AT 13:40.
DISPATCH AND HE JUST NEEDED TO GET THE INFORMATION ON WHAT HAPPENED. I ASKED BOTH PARTIES FOR THEIR DRIVERS LICENSES TO RUN THROUGH DISPATCH ALSO AND THEY BOTH CAME BACK VALID. I ASKED THE RYAN WHAT HAD HAPPENED. HE
STATED HE WAS STOPPED AT THE STOP SIGN ON HOSPITAL ROAD HEADED EAST AND JENNIFER WAS STOPPED BEHIND HIM. HE
STATED A LARGE TRUCK WAS TURNING WEST FROM HWY 63 ONTO HOSPITAL ROAD AND HE DIDNT THINK THERE WAS ENOUGH
ROOM SO HE BACKED UP TO GIVE THE TRUCK MORE ROOM. RYAN STATED WHEN HE LOOKED BACK BEFORE HE BACKED UP HE
DID NOT SEE JENNIFER'S VEHICLE BEHIND HIM. JENNIFER AGREED TO THE STORY. BOTH PARTIES STATED THEY WERE WEARING
THEIR SEATBELTS AND JENNIFER'S BABY IN THE BACK SEAT WAS BUCKLED INTO HER CARSEAT. I NOTICED A CRACKED DENT IN THE FRONT OF JENNIFERS FRONT BUMPER. UPON LOOKING AT THE REST OF THE VEHICLE IT DID NOT APPEAR TO HAVE
ANYMORE DAMAGE. UPON LOOKING AT RYAN'S VEHICLE IT DID NOT APPEAR TO HAVE ANY DAMAGE. IT APPEARED THE HITCH OF
HIS TRUCK HIT HER VEHICLE AND DENTED IT. I TOOK PICTURES OF THE DAMAGED PORTION OF JENNIFER'S VEHICLE AND
ENTERED THEM INTO EVIDENCE. RYAN AND JENNIFER EXCHANGED INFORMATION. I TOLD JENNIFER TO GET AN ESTIMATE ON
HER VEHICLE AND TO LET ME KNOW WHEN SHE GETS ONE. WE ALL CLEARED THE CALL AT 13:40.
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125 - First Name 125 - Middle Initial
Officer Information
ALMOGHRABI125 - Officer Last Name AMBER 340131 - Officer ID
129 - Law Enforcement Agency No.
SAWYER COUNTY SHERIFFS DEPT
130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4858 EXT.
128 - Telephone Number
06/01/2015132 - Date Notified 1319133 - Time Notified (Military Time)1323134 - Time Arrived (Military Time)06/02/2015135 - Date Of Report
15060107090 15060105 19 - Special Study
18 - Agency Space
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