HomeMy WebLinkAbout20151102 GoveAgency Accident Number
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Reportable Accident On Emergency Amended GZDWFR0
DOT Document Number Document Override Number
15110205
15
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2
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5
11/02/2015
4 - Accident Date
1434
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County RADISSON - 12, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
ELM CREEK RD
14 - On Street Name 14 - Bus/Frnt/Rmp
307 FT15 - Est. Distance WEST15 - Hwy. Dir
04016 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.747430
12 - Latitude -91.22666213 - Longitude
OVERTURN80 - 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
SLAG, GRAVEL, OR STONE - 4
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
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Unit Status
OVERTURN
81 - Most Harmful Event: Collision With
WEST
23 - Dir Of Travel
5524 - Speed Limit
B CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2016
31 - Expiration Year 34 - On Duty Accident
GOVE
25 - Operator/Pedestrian Last Name
DIANE
25 - First Name
M
25 - Middle Initial 25 - Suffix
05/20/
32 - Date Of Birth
FEMALE
33 - Sex
26 - Address Street & Number 26 - PO Box
SHELL LAKE
27 - City
WI
27 - State
54871
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.
INATTENTIVE-DRIVING
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
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFR0 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
SOFT-SHOULDER
124 - Highway Factors
TRUCK
21 - Unit Type
STRAIGHT-TRUCK-(INSERT TRUCK)
Vehicle Type
1
22 - Total Occupants
PB8365
56 - License Plate Number
HTK57 - Plate Type WI
58 - State
2015
59 - Exp Year
2610
55 - Vehicle Identification Number
2006
50 - Year
MACK
51 - Make 52 - Model
GG - GARBAGE OR
53 - Body Style
BLU
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT PASSENGER SIDE
94 - Vehicle Damage
MINOR
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
S&R TOWING
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
46 - Vehicle Owner Last Name 46 - First Name 46 - Middle Initial 46 - Suffix Date Of Birth
ALLIED WASTE SERVICES OF NORTH AMERICA LLC46 - Company Name
47- Address Street & Number 47 - PO Box
RICE LAKE48 - City WI48 - State 5486848 - Zip Code 49 - Telephone Number
ACE-AMERICAN-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
REPUBLIC SERVICES61 - 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
Trailer
01
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106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFR0 2 424
105 - Photos By
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Diagram and Narrative
DEPUTY JEFF CAIN
UNIT ONE WAS WESTBOUND ON ELM CREEK RD (GRAVEL) AT APPROXIMATELY 25 MPH WHEN IT GOT TOO CLOSE TO THE SOFT
SHOULDER WHICH GAVE WAY CAUSING UNIT ONE TO ROLL ONTO IT'S SIDE.
UNIT ONE WAS WESTBOUND ON ELM CREEK RD (GRAVEL) AT APPROXIMATELY 25 MPH WHEN IT GOT TOO CLOSE TO THE SOFT
SHOULDER WHICH GAVE WAY CAUSING UNIT ONE TO ROLL ONTO IT'S SIDE.
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125 - First Name 125 - Middle Initial
Officer Information
CAIN125 - Officer Last Name JEFF 314131 - 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
11/02/2015132 - Date Notified 1434133 - Time Notified (Military Time)1505134 - Time Arrived (Military Time)11/03/2015135 - Date Of Report
15110205 19 - Special Study
18 - Agency Space
136
136
136 136
136
Truck and Bus
A truck or truck combination > 10,000 lbs
GVWR/GCWR
Any vehicle displaying a hazardous materials
placard
01
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A vehicle designed to carry 9 or more people, including the driver
136
Fatal Injury Medical Transport
One or more vehicles towed from the scene due to disabling damage
01
Unit Number
137 - Hazardous Materials Class Numbers
137 - Hazardous Materials "UN" Nos.
HazMat Placard Displayed Hazardous Cargo Was Released
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFR0 3 4
137 - Name Of Hazardous Materials in this Load 137 - Name Of Hazardous Materials Released
Interstate Carrier
138 140 - US DOT No.140 - ICC MC No.LC No.IC No.
DRIVER
141 - Source
ALLIED WASTE SERVICES OF NORTH AMERICA LLC
139 - Carrier Name
1207 KNAPP ST
142 - Carrier Address
RICE LAKE
City
WI
State
54868
Zip Code
62,000
143 - GVWR (Lbs)
3
144 - Total No. of Axles
SINGLE-UNIT-TRUCK-3-OR-MORE-AXLES
145 - Vehicle Configuration
GARBAGE/REFUSE
147 - Cargo Body Type
OVERTURN-(ROLLOVER)
146 - First Event
BLANK
146 - Second Event
BLANK
146 - Third Event
BLANK
146 - Fourth Event
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFR0 4 4