HomeMy WebLinkAbout20150606 Helminiak WilsonAgency 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 GZDT72X
DOT Document Number Document Override Number
15060807417
15
0
6
0
8
0
7
4
1
7
15060808
15
0
6
0
8
0
8
06/06/2015
4 - Accident Date
1850
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County SAND LAKE - 14, 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
16 - Fr/At Hwy No.BLUEBERRY RD16 - From/At Street Name 16 - Business/Frontage/Ramp
FIRE #
17 - Structure Type
16618
17 - Structure Number
45.803490
12 - Latitude -91.52360313 - Longitude
PARKED MOTOR VEHICLE80 - First Harmful Event REAR TO REAR93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
SLAG, GRAVEL, OR STONE - 4
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
TRAFFIC SIGN POST
81 - Most Harmful Event: Collision With 23 - Dir Of Travel
1024 - 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 GZDT72X 1 5
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
307GRL
56 - License Plate Number
AUT57 - Plate Type MN
58 - State
2016
59 - Exp Year
534825
55 - Vehicle Identification Number
2011
50 - Year
DODG
51 - Make
4DAMN
52 - Model
4D - 4DR
53 - Body Style
SIL
54 - Color 100 - Skidmarks to Impact (Ft)
REAR
94 - Vehicle Damage
VERY-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
HELMINIAK
46 - Vehicle Owner Last Name
STEVEN
46 - First Name
H
46 - Middle Initial 46 - Suffix
08/26/
Date Of Birth
46 - Company Name
47 - PO Box
RICHFIELD48 - City MN48 - State 5542348 - 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
Unit Status
PARKED MOTOR VEHICLE
81 - Most Harmful Event: Collision With 23 - Dir Of Travel
1024 - 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
WILSON
25 - Operator/Pedestrian Last Name
JACK
25 - First Name
O
25 - Middle Initial 25 - Suffix
03/09/
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 GZDT72X 2 525
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
EDEN PRAIRIE
27 - City
MN
27 - State
55347
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
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
014LSP
56 - License Plate Number
AUT57 - Plate Type MN
58 - State
2015
59 - Exp Year
036109
55 - Vehicle Identification Number
2014
50 - Year
LEXS
51 - Make
4D125
52 - Model
4D - 4DR
53 - Body Style
RED
54 - Color 100 - Skidmarks to Impact (Ft)
NONE
94 - Vehicle Damage
NONE
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
WILSON
46 - Vehicle Owner Last Name
JACK
46 - First Name
O
46 - Middle Initial 46 - Suffix
03/09/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
EDEN PRAIRIE48 - City MN48 - State 5534748 - Zip Code 49 - Telephone Number
FARMERS-INS-CO-INC63 - Liability Insurance Company Policy Holder Same As Owner60
WILSON
61 - Policy Holder Last Name
JACK
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT72X 3 5
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
Fixed Objects Struck
PR
O
P
E
R
T
Y
O
W
N
E
R
Property
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
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 82 - Striking Unit 82 - Object Struck
105 - Photos By
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
ON JUNE 8, 2015, I, DEPUTY AMBER AL-MOGHRABI WAS WORKING PATROL FOR THE SAWYER COUNTY SHERIFF'S DEPARTMENT.
AT APPROXIMATELY 14:22 I WAS ADVISED BY DISPATCH TO CALL DEENA HELMINIAK ABOUT A HIT AND RUN ACCIDENT THAT
HAPPENED SATURDAY JUNE 6. UPON CALLING DEENA SHE STATED ON SATURDAY SHE WAS AT
ON JUNE 8, 2015, I, DEPUTY AMBER AL-MOGHRABI WAS WORKING PATROL FOR THE SAWYER COUNTY SHERIFF'S DEPARTMENT.
AT APPROXIMATELY 14:22 I WAS ADVISED BY DISPATCH TO CALL DEENA HELMINIAK ABOUT A HIT AND RUN ACCIDENT THAT
HAPPENED SATURDAY JUNE 6. UPON CALLING DEENA SHE STATED ON SATURDAY SHE WAS AT
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT72X 4 5
PINE RIDGE IN STONE LAKE FOR DINNER. SHE SAID AT ABOUT 18:50 WHEN SHE WALKED OUT TO HER VEHICLE IN THE PARKING LOT, THAT A WOMAN THAT SHE DID NOT KNOW CAME UP TO HER AND STATED SHE HAD WATCHED A VEHICLE BACK INTO HER
CAR AND LEFT. THE WOMAN INFORMED DEENA THAT THEY GOT A LICENSE PLATE NUMBER FOR HER. DEENA SAID THERE WAS
MINOR DAMAGE BUT THAT THERE WAS A CRACK IN THE RIGHT SIDE OF HER REAR BUMPER. DEENA INFORMED THE LICENSE
PLATE NUMBER FOR THE OTHER VEHICLE WAS 014-LSP FROM MINNESOTA. I INFORMED HER I WOULD HAVE DISPATCH RUN THE
PLATE AND I WOULD TRY TO GET A HOLD OF THE OWNER. I TOLD HER UNTIL THEN TO CALL HER INSURANCE COMPANY. SHE
STATED SHE HAD FARMERS INSURANCE. WHEN ASKED WHY SHE DID NOT REPORT THE ACCIDENT ON SATURDAY, SHE STATED SINCE IT WAS MINOR THAT WE WOULD NOT COME. I CLEARED THE PHONE CALL AT 15:18 AND HAD DISPATCH RUN THE OTHER
PLATE WHICH CAME BACK TO JACK WINSLOW OF EDEN PRAIRIE. DISPATCH WAS ABLE TO LOCATE A PHONE NUMBER FOR JACK.
THERE WAS NO ANSWER SO I LEFT A VOICEMAIL. AT APPROXIMATELY 16:55 I RECEIVED A CALL FROM JACK. HE STATED HE DID
BACK INTO A VEHICLE AT PINE RIDGE ON SATURDAY NIGHT, BUT HE DID NOT SEE ANY DAMAGE SO HE LEFT. I INFORMED HIM
THAT THERE WAS MINOR DAMAGE AND THAT HE SHOULD CONTACT HIS INSURANCE COMPANY AND INFORM THEM OF THE
INCIDENT. I ALSO INFORMED HIM I WOULD BE DOING AN ACCIDENT REPORT. I CLEARED THE CALL AT 17:00. THIS IS ALL THE
INFORMATION I HAVE AT THIS TIME.
PINE RIDGE IN STONE LAKE FOR DINNER. SHE SAID AT ABOUT 18:50 WHEN SHE WALKED OUT TO HER VEHICLE IN THE PARKING LOT, THAT A WOMAN THAT SHE DID NOT KNOW CAME UP TO HER AND STATED SHE HAD WATCHED A VEHICLE BACK INTO HER
CAR AND LEFT. THE WOMAN INFORMED DEENA THAT THEY GOT A LICENSE PLATE NUMBER FOR HER. DEENA SAID THERE WAS
MINOR DAMAGE BUT THAT THERE WAS A CRACK IN THE RIGHT SIDE OF HER REAR BUMPER. DEENA INFORMED THE LICENSE
PLATE NUMBER FOR THE OTHER VEHICLE WAS 014-LSP FROM MINNESOTA. I INFORMED HER I WOULD HAVE DISPATCH RUN THE
PLATE AND I WOULD TRY TO GET A HOLD OF THE OWNER. I TOLD HER UNTIL THEN TO CALL HER INSURANCE COMPANY. SHE
STATED SHE HAD FARMERS INSURANCE. WHEN ASKED WHY SHE DID NOT REPORT THE ACCIDENT ON SATURDAY, SHE STATED SINCE IT WAS MINOR THAT WE WOULD NOT COME. I CLEARED THE PHONE CALL AT 15:18 AND HAD DISPATCH RUN THE OTHER
PLATE WHICH CAME BACK TO JACK WINSLOW OF EDEN PRAIRIE. DISPATCH WAS ABLE TO LOCATE A PHONE NUMBER FOR JACK.
THERE WAS NO ANSWER SO I LEFT A VOICEMAIL. AT APPROXIMATELY 16:55 I RECEIVED A CALL FROM JACK. HE STATED HE DID
BACK INTO A VEHICLE AT PINE RIDGE ON SATURDAY NIGHT, BUT HE DID NOT SEE ANY DAMAGE SO HE LEFT. I INFORMED HIM
THAT THERE WAS MINOR DAMAGE AND THAT HE SHOULD CONTACT HIS INSURANCE COMPANY AND INFORM THEM OF THE
INCIDENT. I ALSO INFORMED HIM I WOULD BE DOING AN ACCIDENT REPORT. I CLEARED THE CALL AT 17:00. THIS IS ALL THE
INFORMATION I HAVE AT THIS TIME.
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
ALMOGHRABI
125 - Officer Last Name
AMBER 340
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
06/08/2015
132 - Date Notified 1422133 - Time Notified (Military Time)1422134 - Time Arrived (Military Time)
06/10/2015
135 - Date Of Report
15060807417 15060808 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT72X 5 5