HomeMy WebLinkAbout20151126 PetersonAgency Accident Number
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Reportable Accident On Emergency Amended GZDNRQT
DOT Document Number Document Override Number
15112601
15
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11/26/2015
4 - Accident Date
1458
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County EDGEWATER - 04, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
F
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
426 FT15 - Est. Distance SOUTH15 - Hwy. Dir
16 - Fr/At Hwy No.ARROWHEAD LN 2916 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.700100
12 - Latitude -91.52148713 - Longitude
TREE80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
113 - Road Curvature
HILL
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
DIVIDED-HIGHWAY-MEDIAN-STRIP-WITHOUT-TRAFFIC-BARRIER115 - Traffic Way
OFF-ROADWAY-LOCATION-UNKNOWN
117 - Relation To Roadway
DAYLIGHT114 - Light Condition ICE116 - 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
TREE
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
29 - Driver's License Number
WI
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
PETERSON
25 - Operator/Pedestrian Last Name
BRADLEY
25 - First Name
S
25 - Middle Initial
II
25 - Suffix
01/14/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
RICE LAKE
27 - City
WI
27 - State
54868
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 NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
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 GZDNRQT 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
256XEJ
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
0768
55 - Vehicle Identification Number
2002
50 - Year
BUIC
51 - Make
CENTURY
52 - Model
4D - 4DR
53 - Body Style
MAR
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT DRIVER SIDE, FRONT PASSENGER SIDE, MIDDLE PASSENGER SIDE
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
SWANT TOWING
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
PETERSON
46 - Vehicle Owner Last Name
BRADLEY
46 - First Name
S
46 - Middle Initial
II
46 - Suffix
01/14
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
RICE LAKE48 - City WI48 - State 5486848 - Zip Code 49 - Telephone Number
AMERICAN-FAMILY63 - Liability Insurance Company Policy Holder Same As Owner60
PETERSON
61 - Policy Holder Last Name
BRADLEY
61 - Policy Holder First Name
61 - Policy Holder Company
01
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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
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MV4000e 01/2005
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Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDNRQT 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
TREE
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
DEPUTY MATTHEW JEFSON
DISPATCH ADVISED ME THAT THEY RECEIVED A CALL FROM SWANT TOWING IN REFERENCE TO A VEHICLE IN THE DITCH. I
RESPONDED TAND ARRIVED ON SCENE AND NOTICED A VEHICLE HAD SLIDE OFF THE ROADWAY AND DOWN A HILL, HITTING A
COUPLE OF TREES. I SPOKE WITH THE DRIVER OF THE VEHICLE WHO STATED THAT HE WAS GOING ABOUT 25-30 MPH AND HAD
JUST STARTED TO SLOW FOR THE TURN WHEN HIS VEHICLE STARTED TO SLIDE STRAIGHT INTO THE DITCH AND HIT A COUPLE
TREES. DRIVER SAID THAT HE WAS WEARING HIS SEAT BELT. THE ROADWAY WAS ICY. SWANT TOWING ARRIVED ON SCENE AND I
TOOK PHOTOS BEFORE THE VEHICLE WAS REMOVED. TTHE VEHICLE WAS TAKEN TO THE DRIVERS FATHERS HOUSE. I CLEARED FROM THE SCENE.
DISPATCH ADVISED ME THAT THEY RECEIVED A CALL FROM SWANT TOWING IN REFERENCE TO A VEHICLE IN THE DITCH. I
RESPONDED TAND ARRIVED ON SCENE AND NOTICED A VEHICLE HAD SLIDE OFF THE ROADWAY AND DOWN A HILL, HITTING A
COUPLE OF TREES. I SPOKE WITH THE DRIVER OF THE VEHICLE WHO STATED THAT HE WAS GOING ABOUT 25-30 MPH AND HAD
JUST STARTED TO SLOW FOR THE TURN WHEN HIS VEHICLE STARTED TO SLIDE STRAIGHT INTO THE DITCH AND HIT A COUPLE
TREES. DRIVER SAID THAT HE WAS WEARING HIS SEAT BELT. THE ROADWAY WAS ICY. SWANT TOWING ARRIVED ON SCENE AND I
TOOK PHOTOS BEFORE THE VEHICLE WAS REMOVED. TTHE VEHICLE WAS TAKEN TO THE DRIVERS FATHERS HOUSE. I CLEARED FROM THE SCENE.
Officer Information
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDNRQT 3 4
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125 - First Name 125 - Middle Initial
JEFSON
125 - Officer Last Name
MATTHEW 324
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
11/26/2015
132 - Date Notified 1519133 - Time Notified (Military Time)1521134 - Time Arrived (Military Time)
12/04/2015
135 - Date Of Report
15112601 19 - Special Study
18 - Agency Space
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDNRQT 4 4