HomeMy WebLinkAbout20150801 KochAgency Accident Number
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Reportable Accident On Emergency Amended GZDT733
DOT Document Number Document Override Number
15080110472
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15080104
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08/01/2015
4 - Accident Date
1244
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County WINTER - 17, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
W
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
409 FT15 - Est. Distance EAST15 - Hwy. Dir
16 - Fr/At Hwy No.TURCOTTE CORNER16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.827067
12 - Latitude -91.02284413 - 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
SHOULDER-(OTHER THAN SHOULDER WITHIN MEDIAN OR GORE)
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
DITCH
81 - Most Harmful Event: Collision With
EAST
23 - Dir Of Travel
3524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
KOCH
25 - Operator/Pedestrian Last Name
DONALD
25 - First Name
S
25 - Middle Initial 25 - Suffix
07/21
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
WINTER
27 - City
WI
27 - State
54896
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
B - NON-INCAPACITATING 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
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Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDT733 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
648LSR
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
8468
55 - Vehicle Identification Number
1999
50 - Year
DODG
51 - Make
CARAVAN
52 - Model
VN - VAN
53 - Body Style
BLU
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, TOP OF VEHICLE
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
KOCH
46 - Vehicle Owner Last Name
DONALD
46 - First Name
S
46 - Middle Initial 46 - Suffix
07/21
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
WINTER48 - City WI48 - State 5489648 - Zip Code 49 - Telephone Number
ALLSTATE-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
KOCH
61 - Policy Holder Last Name
DONALD
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
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
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Wisconsin Motor Vehicle
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Wisconsin Motor Vehicle GZDT733 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
AMBER AL-MOGHRABI
ON AUGUST 1, 2015 I, DEPUTY AMBER AL-MOGHRABI, WAS DISPATCHED TO CTY ROAD W BY THE TRAILER PARK FOR A ONE
VEHICLE ROLLOVER AT APPROXIMATLY 12:42. UPON ARRIVAL AT 13:03, I NOTICED A BLUE VAN LAYING ON ITS ROOF IN THE
NORTH DITCH OFF CTY ROAD W. IT APPEARED TO HAVE SEVERE DAMAGE TO THE ROOF AND FRONT END OF THE VEHICLE. I
SPOKE WITH THE DRIVER DONALD KOCH, WHO WAS BEING LOOKED AT BY THE PARADMEDICS ON SCENE DUE TO A HURT ARM.
HE STATED HE WAS TRAVELING EAST ON COUNTY ROAD W AT APPROXIMATELY 40 MPH WHEN HIS VEHICLE HIT THE SHOULDER
OF THE ROAD. HE STATED HE TRIED TO CORRECT THE TURN AND LOST CONTROL OF THE VEHICLE WHERE HE CROSSED BOTH LANES AND ROLLED ON THE NORTH SHOULDER OF W. DONALD STATED HE WAS WEARING HIS SEATBELT AND HAS ALL STATE
INSURANCE. I TOOK PICTURES OF THE VEHICLE AND WILL BE ENTERING THEM INTO EVIDENCE. THE AMBULANCE TOOK DONALD
TO HAYWARD AREA MEMORIAL HOSPITAL AND THE VEHICLE WAS TOWED BY ROADRUNNER TOWING. I CLEARED THE CALL AT
15:24.
ON AUGUST 1, 2015 I, DEPUTY AMBER AL-MOGHRABI, WAS DISPATCHED TO CTY ROAD W BY THE TRAILER PARK FOR A ONE
VEHICLE ROLLOVER AT APPROXIMATLY 12:42. UPON ARRIVAL AT 13:03, I NOTICED A BLUE VAN LAYING ON ITS ROOF IN THE
NORTH DITCH OFF CTY ROAD W. IT APPEARED TO HAVE SEVERE DAMAGE TO THE ROOF AND FRONT END OF THE VEHICLE. I
SPOKE WITH THE DRIVER DONALD KOCH, WHO WAS BEING LOOKED AT BY THE PARADMEDICS ON SCENE DUE TO A HURT ARM.
HE STATED HE WAS TRAVELING EAST ON COUNTY ROAD W AT APPROXIMATELY 40 MPH WHEN HIS VEHICLE HIT THE SHOULDER
OF THE ROAD. HE STATED HE TRIED TO CORRECT THE TURN AND LOST CONTROL OF THE VEHICLE WHERE HE CROSSED BOTH LANES AND ROLLED ON THE NORTH SHOULDER OF W. DONALD STATED HE WAS WEARING HIS SEATBELT AND HAS ALL STATE
INSURANCE. I TOOK PICTURES OF THE VEHICLE AND WILL BE ENTERING THEM INTO EVIDENCE. THE AMBULANCE TOOK DONALD
TO HAYWARD AREA MEMORIAL HOSPITAL AND THE VEHICLE WAS TOWED BY ROADRUNNER TOWING. I CLEARED THE CALL AT
15:24.
Officer Information
Accident Report
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Wisconsin Motor Vehicle GZDT733 3 4
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125 - First Name 125 - Middle Initial
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
08/01/2015
132 - Date Notified 1244133 - Time Notified (Military Time)1303134 - Time Arrived (Military Time)
08/01/2015
135 - Date Of Report
15080110472 15080104 19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT733 4 4