HomeMy WebLinkAbout20150709 StoneAgency Accident Number
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Reportable Accident On Emergency Amended GZDVPJD
DOT Document Number Document Override Number
15070909131
15
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15070904
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07/09/2015
4 - Accident Date
0843
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County COUDERAY - 02, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
027
14 - On Hwy No.
NB
14 - On Street Name 14 - Bus/Frnt/Rmp
847 FT15 - Est. Distance WEST15 - Hwy. Dir
16 - Fr/At Hwy No.RIVER RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.797041
12 - Latitude -91.36953713 - Longitude
DITCH80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - 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
OUTSIDE-SHOULDER-RIGHT
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
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Unit Status
DITCH
81 - Most Harmful Event: Collision With
WEST
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
WI
30 - State
2017
31 - Expiration Year 34 - On Duty Accident
STONE
25 - Operator/Pedestrian Last Name 25 - First Name 25 - Middle Initial 25 - Suffix
09/24/
32 - Date Of Birth
MALE
33 - Sex
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
GOING-STRAIGHT
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 062 - No. of Citations Issued
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
INATTENTIVE-DRIVING, FAILURE-TO-HAVE-CONTROL
122 - Driver Factors
REDUCED ALERTNESS88 - 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 GZDVPJD 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
2
22 - Total Occupants
508WWB
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2015
59 - Exp Year
7352
55 - Vehicle Identification Number
1994
50 - Year
BUIC
51 - Make
SKYLARK
52 - Model
4D - 4DR
53 - Body Style
MAR
54 - Color
0100 - Skidmarks to Impact (Ft)
UNDERCARRIAGE, FRONT DRIVER SIDE, FRONT PASSENGER SIDE
94 - Vehicle Damage
MODERATE
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
TESCHENDORF
46 - Vehicle Owner Last Name
RACHEL
46 - First Name
LYNN
46 - Middle Initial 46 - Suffix
02/17/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
PROGRESSIVE-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
TESCHENDORF
61 - Policy Holder Last Name
RACHEL
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
Occupant
Address Same As Operator
OC
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01
65 - Unit No
K
66 - Occupant Last Name
H
66 - First Name 66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
STONE LAKE
68 - City
WI
68 - State
54876
68 - Zip Code
M69 - 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 GZDVPJD 2 424
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
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106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
Fixed Objects Struck
PR
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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
POPLIN
ON JULY 9TH, 2015 UNIT 1 WAS GOING WEST ON STATE HWY 27/70 BETWEEN COUNTY HWY C AND SIGNOR DR. THE DRIVER OF
UNIT1 SAID HE FELL ASLEEP AND LEFT THE ROADWAY. THE DRIVER SAID HE WOKE UP AND HE WAS IN THE DITCH AT WHICH
POINT HE CORRECTED BACK ONTO THE ROADWAY. WHILE ENTERING BACK ONTO THE ROAD UNIT 1 SUSTAINED MODERATE DAMAGE TO THE UNDERCARRIAGE AND BOTH FRONT TIRES WERE FLAT AS WELL.
ON JULY 9TH, 2015 UNIT 1 WAS GOING WEST ON STATE HWY 27/70 BETWEEN COUNTY HWY C AND SIGNOR DR. THE DRIVER OF
UNIT1 SAID HE FELL ASLEEP AND LEFT THE ROADWAY. THE DRIVER SAID HE WOKE UP AND HE WAS IN THE DITCH AT WHICH
POINT HE CORRECTED BACK ONTO THE ROADWAY. WHILE ENTERING BACK ONTO THE ROAD UNIT 1 SUSTAINED MODERATE DAMAGE TO THE UNDERCARRIAGE AND BOTH FRONT TIRES WERE FLAT AS WELL.
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJD 3 4
OF
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125 - First Name 125 - Middle Initial
Officer Information
POPLIN
125 - Officer Last Name
JAY 352
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
07/09/2015
132 - Date Notified 0843133 - Time Notified (Military Time)0906134 - Time Arrived (Military Time)
07/09/2015
135 - Date Of Report
15070909131 15070904 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJD 4 4