HomeMy WebLinkAbout20150704 HolmbergAgency 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 GZDT730
DOT Document Number Document Override Number
15070408836
15
0
7
0
4
0
8
8
3
6
15070404
15
0
7
0
4
0
4
07/04/2015
4 - Accident Date
1038
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 06, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
B
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
291 FT15 - Est. Distance WEST15 - Hwy. Dir
16 - Fr/At Hwy No.FELSER RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.996992
12 - Latitude -91.39731713 - Longitude
MAILBOX80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - 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 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
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
Unit Status
MAILBOX
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
2018
31 - Expiration Year 34 - On Duty Accident
HOLMBERG
25 - Operator/Pedestrian Last Name
GARRY
25 - First Name
MICHAEL
25 - Middle Initial 25 - Suffix
11/24/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
ANDOVER
27 - City
MN
27 - State
55304
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
GOING-STRAIGHT
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
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
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT730 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
3
22 - Total Occupants
947LRR
56 - License Plate Number
AUT57 - Plate Type MN
58 - State
2015
59 - Exp Year
8913
55 - Vehicle Identification Number
2001
50 - Year
FORD
51 - Make
CWSRW
52 - Model
PK - PICKUP
53 - Body Style
WHI
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT PASSENGER SIDE, MIDDLE PASSENGER SIDE
94 - Vehicle Damage
MODERATE
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
HOLMBERG
46 - Vehicle Owner Last Name
GARRY
46 - First Name
MICHAEL
46 - Middle Initial 46 - Suffix
11/24/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
ANDOVER48 - City MN48 - State 5530448 - 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
Occupant
Address Same As Operator
OC
C
U
P
A
N
T
01
65 - Unit No
HOLMBERG
66 - Occupant Last Name
LINDA
66 - First Name
KAY
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
ANDOVER
68 - City
MN
68 - State
55304
68 - Zip Code
10/04/67 - Date of Birth F69 - Sex
FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER)
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
72 - Safety Equipment
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT730 2 424
C - POSSIBLE INJURY
70 - Injury Severity
NON-DEPLOYED
73 - Airbag
NOT-EJECTED
75 - Ejected
Medical Transport
77
NOT-TRAPPED
76 - Trapped/Extricated 78 - Agency Space
Occupant
Address Same As Operator
OC
C
U
P
A
N
T
01
65 - Unit No
HOLMBERG
66 - Occupant Last Name
HUNTER
66 - First Name
LEE
66 - Middle Initial 66 - Suffix
02
68 - Address Street & Number 68 - PO Box
ANDOVER
68 - City
MN
68 - State
55304
68 - Zip Code
08/15
67 - Date of Birth
M
69 - Sex
SECOND-SEAT-RIGHT
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-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
Fixed Objects Struck
PR
O
P
E
R
T
Y
O
W
N
E
R
Property
ORGANIZATION
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
COMPLETE WELDING
84 - Company Name Government Property Type
85 - Address Street & Number 85 - PO Box
HAYWARD
86 - City
WI
86 - State
54843
86 - Zip Code 87 - Telephone Number
83 - Government Damage Tag Number
01
82 - Striking Unit
MAILBOX
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
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT730 3 4
105 - Photos By
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
DEPUTY AMBER AL-MOGHRABI
ON JULY 4, 2015 AT APPROXIMATELY 10:39 AM, SAWYER COUNTY DISPATCHED ADVISED ME TO GO TO COMPLETE WELDING ON
COUNTY ROAD B FOR A 1 VEHICLE ACCIDENT. UPON ARRIVAL AT 11:01 I SPOKE WITH THE DRIVER OF THE TRUCK THAT WAS
DAMAGED. HE STATED HIS NAME WAS GARRY AND THAT THE VEHICLE THAT WAS PARKED NEXT TO HIM PULLED OUT IN FRONT
OF HIM AND MADE HIM HIT THE MAILBOX. I ASKED GARRY TO ELABORATE ON WHAT HAPPENED. HE STATED HE WAS TRAVELING EASTBOUND ON COUNTY ROAD B AND AS HE WAS PASSING THE PARKING LOT FOR COMPLETE WELDING A GREEN FORD TAURUS
THAT WAS HEADING WESTBOUND ON COUNTY ROAD B STARTING TURNING LEFT INTO THE PARKING LOT OF COMPLETE WELDING.
GARRY STATED THAT HE NOTICED THE TAURUS SLAM ON THE BREAKS AND THAT GARRY STEARED THE CAR TOWARDS THE
RIGHT SHOULDER AND SLAMMED ON HIS BREAKS SO THAT HE WOULD NOT GET HIT. HE STATED THAT AT THAT POINT HE
CORRECTED HIS TURN SO HE WOULD NOT END UP IN THE WOODS AND HIT THE MAILBOX INSTEAD. GARRY STATED PART OF THE
PASSENGER SIDE MIRROR FLEW OFF AND HIT HIM IN THE HEAD, BUT HE WAS OK. HE STATED THE PASSENGER SIDE WINDOW
SHATTERED AND FELL ON HIS WIFE, LINDA'S, LAP. I NOTICED THE TRUCK HAD MODERATE DAMAGE. THERE WAS A DENT ON THE
PASSENGER SIDE OF THE TRUCK THAT WENT TO THE BEGINNING OF THE PASSENGER SIDE DOOR. THE PASSENGER SIDE
MIRROR WAS BENT IN AND THE MIRROR FLEW OFF, AND THE PASSENGER WINDOW WAS SHATTERED. I CALLED DISPATCH FOR
AN EMT AND AMBULANCE FOR LINDA, WHO HAD GLASS STUCK IN HER LEG AND A PREVIOUS NECK INJURY. THE EMT BELIEVED
SHE SHOULD GET CHECKED OUT AT THE HOSPITAL. GARRY STATED AFTER HE HIT THE MAILBOX HE REVERSED INTO THE
DRIVEWAY OF COMPLETE WELDING WHERE THE OTHER DRIVER PULLED IN ALSO. I SPOKE TO ALLAN MAHNKE WHO WAS DRIVING
THE OTHER VEHICLE. HE EXPLAINED THE SAME STORY TO ME THAT GARRY DID AND SAID IT WAS ALL HIS FAULT. ALLAN STATED HE HAD HEARTFORD INSURANCE AND THAT HE WOULD CONTACT THEM AS SOON AS POSSIBLE. SEE REPORT FOR MORE
DETAILED DESCRIPTION. END OF REPORT.
ON JULY 4, 2015 AT APPROXIMATELY 10:39 AM, SAWYER COUNTY DISPATCHED ADVISED ME TO GO TO COMPLETE WELDING ON
COUNTY ROAD B FOR A 1 VEHICLE ACCIDENT. UPON ARRIVAL AT 11:01 I SPOKE WITH THE DRIVER OF THE TRUCK THAT WAS
DAMAGED. HE STATED HIS NAME WAS GARRY AND THAT THE VEHICLE THAT WAS PARKED NEXT TO HIM PULLED OUT IN FRONT
OF HIM AND MADE HIM HIT THE MAILBOX. I ASKED GARRY TO ELABORATE ON WHAT HAPPENED. HE STATED HE WAS TRAVELING EASTBOUND ON COUNTY ROAD B AND AS HE WAS PASSING THE PARKING LOT FOR COMPLETE WELDING A GREEN FORD TAURUS
THAT WAS HEADING WESTBOUND ON COUNTY ROAD B STARTING TURNING LEFT INTO THE PARKING LOT OF COMPLETE WELDING.
GARRY STATED THAT HE NOTICED THE TAURUS SLAM ON THE BREAKS AND THAT GARRY STEARED THE CAR TOWARDS THE
RIGHT SHOULDER AND SLAMMED ON HIS BREAKS SO THAT HE WOULD NOT GET HIT. HE STATED THAT AT THAT POINT HE
CORRECTED HIS TURN SO HE WOULD NOT END UP IN THE WOODS AND HIT THE MAILBOX INSTEAD. GARRY STATED PART OF THE
PASSENGER SIDE MIRROR FLEW OFF AND HIT HIM IN THE HEAD, BUT HE WAS OK. HE STATED THE PASSENGER SIDE WINDOW
SHATTERED AND FELL ON HIS WIFE, LINDA'S, LAP. I NOTICED THE TRUCK HAD MODERATE DAMAGE. THERE WAS A DENT ON THE
PASSENGER SIDE OF THE TRUCK THAT WENT TO THE BEGINNING OF THE PASSENGER SIDE DOOR. THE PASSENGER SIDE
MIRROR WAS BENT IN AND THE MIRROR FLEW OFF, AND THE PASSENGER WINDOW WAS SHATTERED. I CALLED DISPATCH FOR
AN EMT AND AMBULANCE FOR LINDA, WHO HAD GLASS STUCK IN HER LEG AND A PREVIOUS NECK INJURY. THE EMT BELIEVED
SHE SHOULD GET CHECKED OUT AT THE HOSPITAL. GARRY STATED AFTER HE HIT THE MAILBOX HE REVERSED INTO THE
DRIVEWAY OF COMPLETE WELDING WHERE THE OTHER DRIVER PULLED IN ALSO. I SPOKE TO ALLAN MAHNKE WHO WAS DRIVING
THE OTHER VEHICLE. HE EXPLAINED THE SAME STORY TO ME THAT GARRY DID AND SAID IT WAS ALL HIS FAULT. ALLAN STATED HE HAD HEARTFORD INSURANCE AND THAT HE WOULD CONTACT THEM AS SOON AS POSSIBLE. SEE REPORT FOR MORE
DETAILED DESCRIPTION. END OF REPORT.
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
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
07/04/2015132 - Date Notified 1039133 - Time Notified (Military Time)1101134 - Time Arrived (Military Time)07/04/2015135 - Date Of Report
15070408836 15070404 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT730 4 4