HomeMy WebLinkAbout20151013 Melton TaylorAgency Accident Number
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Reportable Accident On Emergency Amended GZDVPJH
DOT Document Number Document Override Number
15101314659
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15101306
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10/13/2015
4 - Accident Date
1525
5 - Time of Accident (Military Time)
02
6 - Total Units
02
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County BASS LAKE - 01, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
E
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
0.43 MI15 - Est. Distance NORTH15 - Hwy. Dir
16 - Fr/At Hwy No.WILLIAMS RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.971610
12 - Latitude -91.43127113 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event HEAD ON93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
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
1510131465979 - E M S Number
Operator/Pedestrian
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Unit Status
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
SOUTH
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
2022
31 - Expiration Year 34 - On Duty Accident
MELTON
25 - Operator/Pedestrian Last Name
TIFFANY
25 - First Name
MAE
25 - Middle Initial 25 - Suffix
06/03
32 - Date Of Birth
FEMALE
33 - Sex
& 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
A - INCAPACITATING INJURY
38 - Injury Severity
UNKNOWN
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 262 - No. of Citations Issued
346.05(1)
64 - 1st Statute No.
344.62(1)
64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
INATTENTIVE-DRIVING, LEFT-OF-CENTER, FAILURE-TO-HAVE-CONTROL
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 GZDVPJH 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
JL7147
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
7476
55 - Vehicle Identification Number
1995
50 - Year
CHEV
51 - Make
BLAZER
52 - Model
UT - SPORT UTILITY
53 - Body Style
WHI
54 - Color
0100 - Skidmarks to Impact (Ft)
TOTAL (DAMAGE TO ALL AREAS)
94 - Vehicle Damage
VERY-SEVERE
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
MELTON
46 - Vehicle Owner Last Name
TIFFANY
46 - First Name
MAE
46 - Middle Initial 46 - Suffix
06/03/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
NONE63 - 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
MOTOR VEHICLE IN TRANSPORT
81 - Most Harmful Event: Collision With
NORTH
23 - Dir Of Travel
5524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
8309
29 - Driver's License Number
WI
30 - State
2016
31 - Expiration Year 34 - On Duty Accident
TAYLOR
25 - Operator/Pedestrian Last Name
NELLE
25 - First Name
F
25 - Middle Initial 25 - Suffix
05/23/1
32 - Date Of Birth
FEMALE
33 - Sex
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJH 2 424
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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
A - INCAPACITATING INJURY
38 - Injury Severity
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.
NOT-APPLICABLE
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST GIVEN, ALCOHOL UNKNOWN90 - Alcohol Test 90 - Alcohol Content TEST GIVEN DRUGS UNKNOWN91 - Drug Test
91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
608WHS
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
580
55 - Vehicle Identification Number
2005
50 - Year
BUIC
51 - Make 52 - Model
4D - 4DR
53 - Body Style
SIL
54 - Color
0100 - Skidmarks to Impact (Ft)
TOTAL (DAMAGE TO ALL AREAS)
94 - Vehicle Damage
VERY-SEVERE
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
BRUCE
46 - Vehicle Owner Last Name
TALYOR
46 - First Name
A
46 - Middle Initial 46 - Suffix
11/09/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
CENTURY-NATIONAL-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
BRUCE
61 - Policy Holder Last Name
TALYOR
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJH 3 4
School Bus
02
BU
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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
105 - Photos By
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Diagram and Narrative
POPLIN AND AL-MOGHRABI
UNIT 1 WAS GOING SOUTH ON COUNTY HWY E AND NEGOTIATING A CURVE. UNIT 2 WAS GOING NORTH ON COUNTY HWY E NEGOTIATING THE SAME CURVE. UNIT 1 CROSSED THE CENTER LINE INTO UNIT 2'S LANE CAUSING A HEAD ON COLLISION WHERE
BOTH VEHICLES SUSTAINED SEVERE DAMAGE AND ALSO BOTH DRIVERS SUSTAINED INCAPACITATING INJURIES. BOTH DRIVER'S
WERE TRANSPORTED BY AMBULANCE AND THE DRIVER OF UNIT 1 WAS TRANSFERED TO A HELICOPTER AND FLEW OUT. THE
VEHICLES WERE TOWED BY ROAD RUNNER TOWING.
UNIT 1 WAS GOING SOUTH ON COUNTY HWY E AND NEGOTIATING A CURVE. UNIT 2 WAS GOING NORTH ON COUNTY HWY E NEGOTIATING THE SAME CURVE. UNIT 1 CROSSED THE CENTER LINE INTO UNIT 2'S LANE CAUSING A HEAD ON COLLISION WHERE
BOTH VEHICLES SUSTAINED SEVERE DAMAGE AND ALSO BOTH DRIVERS SUSTAINED INCAPACITATING INJURIES. BOTH DRIVER'S
WERE TRANSPORTED BY AMBULANCE AND THE DRIVER OF UNIT 1 WAS TRANSFERED TO A HELICOPTER AND FLEW OUT. THE
VEHICLES WERE TOWED BY ROAD RUNNER TOWING.
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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
10/13/2015
132 - Date Notified 1525133 - Time Notified (Military Time)1529134 - Time Arrived (Military Time)
10/15/2015
135 - Date Of Report
15101314659 15101306 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDVPJH 4 4