OFFICE USE ONLY
(608) 356-4895
Secondary
Crash
Amended
Crash TypeDT4000 (STANDARD CRASH)
Reportable
Tags School Bus RelatedNO
Active School Zone
Government
Property
Reporting
Threshold
Trailer or Towed
Work Zone
Lane Closure
Hit and Run
On Emergency
Total Killed00
Total Injured01
Total Units02
Time Notified04:58 PM
Date Notified08/28/2020
Time Arrived05:18 PM
Date Arrived08/28/2020
Crash Time04:58 PM
Crash Date08/28/2020
Investigating Officer/DeputyDEPUTY K. MUELLER
Agency Crash Number
20-10563
Primary Crash Document # Document Number Override
6TL0D7W13K
Structure Type Tribal Land
Override
On Roadway Link Offset
1084
On Roadway Link ID#
4557413
Y Coordinate4809638
X Coordinate287344.75
Access Control Lat/LongSourceTLT/ILT
Longitude-89.6264554
Latitude43.40947098
ON CTHDL EB
1084 FT E
OF BLUFF RD
IN THE TOWN OF MERRIMAC
IN SAUK COUNTY
Location
Special Study Access ControlNO CONTROL
Tribal LandCrash Classification - Jurisdiction
NO SPECIAL JURISDICTION
Crash Classification - Location
PUBLIC PROPERTY
Relation To TrafficwayTRAFFICWAY - ON ROAD
Animal Type Weather Condition(s)CLOUDY
Roadway Factor(s)NONE
Environment Factor(s)NONE
Road Surface Condition(s)
DRY
Light Condition
DAYLIGHT
Manner of Collision
07 - SIDESWIPE/SAME DIRECTION
First Harmful Event Location
ROADSIDE
First Harmful Event
MOTOR VEH IN TRANSPORT
Crash Scene
Intersection Type
NOT AN INTERSECTION
Junction Location
NON-JUNCTION
Within Interchange Area
NO
Truck Bus or HazMat
NO
Road GradeDOWNHILL
Road CurvatureSTRAIGHT
Surface TypeBLACKTOP (BITUMINOUS)
Traffic Control Inoperative/Missing
NO
Traffic Control
NO CONTROL
Traffic Way
TWO-WAY, NOT DIVIDED
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTION
Most Harmful Event: Collision With
MOTOR VEH IN TRANSPORT
Total Lanes
2
Speed Limit55
Pre CrashTire
Mark
Direction Of TravelEASTBOUND
Insurance?YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
1
Train/Bus # Recorded Total Occs2
Operating As Endorsements Vehicle Type(SPORT) UTILITY VEHICLE
Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit StatusIN TRANSIT
UNIT
01
01
Unit Summary
Crash Date08/28/2020
OFFICE USE ONLY
(608) 356-4895
Drug & Alcoh
Injury
Drug Type
Drug Test Results Drug Test Type
Drug Test Given
TEST NOT GIVEN
Alcohol Test Results Alcohol Test Type
Alcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
INDIVIDUAL
UNIT
Individual ConditionAPPEARED NORMAL
Action Other Distracted By SourceUNKNOWN
Distracted By ActionUNKNOWN
Action Prior Action To/FromSchool Location Striking Unit #01
Time of Death Date of Death Hospital EMS Run # EMS Agency IdentifierMedicalTransport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICA
Ejected
NOT EJECTED
AirbagNON DEPLOYED
Injury SeverityNO APPARENT INJURY
INDIVIDUAL
UNIT
Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position07 - LEFT
Row01 - FRONT ROW
Safety EquipmentSHOULDER & LAP BELT
On Duty Accident
01
DL Expire Year2023
License StatusVALID LICENSE
License TypeNON-CDL DRIVER'S LICENSE
Country of Issuance
UNITED STATES
License JursidictionSTATE
StateIL
Driver's License Number
Phone Number
(773) 961-5533 EXT.
Weight110
Height411
EyesBROWN
HairBROWN
RaceH
SexF
DOB Country of ResidenceUNITED STATES
Zip Code61618
StateIL
CityCHICAGO
PO Box Street Address 2 Street Address4038 N WHIPPLE ST
Suffix Middle Initial First NameALEXIS
Last NameACEVEDO
Individual TypeINDIVIDUAL
Use Driver
Address
Citations Issued1
RoleDRIVER
INDIVIDUAL
01
UNIT
01
Non Motorist
Equipment
Country of ResidenceUNITED STATES
Zip Code60609
StateIL
CityCHICAGO
PO Box Street Address 2 Street Address3601 S SEELEY AVE
Suffix Middle Initial First NameCHRISTINA
Last NameSANCHEZ
Individual TypeINDIVIDUAL
Use Driver
Address
Citations Issued0
RolePASSENGER
02
01
Crash Date08/28/2020
OFFICE USE ONLY
(608) 356-4895
Drug & Alcoh
Injury
Drug Type
Drug Test Results Drug Test Type
Drug Test Given
TEST NOT GIVEN
Alcohol Test Results Alcohol Test Type
Alcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
INDIVIDUAL
UNIT
Individual ConditionAPPEARED NORMAL
Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #02
Time of Death Date of Death Hospital EMS Run # EMS Agency IdentifierMedicalTransport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICA
Ejected
NOT EJECTED
AirbagNON DEPLOYED
Injury SeverityNO APPARENT INJURY
INDIVIDUAL
UNIT
Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position09 - RIGHT
Row01 - FRONT ROW
Safety EquipmentSHOULDER & LAP BELT
On Duty Accident
02
DL Expire Year2024
License StatusVALID LICENSE
License TypeNON-CDL DRIVER'S LICENSE
Country of Issuance
UNITED STATES
License JursidictionSTATE
StateIL
Driver's License Number
Phone Number Weight
185
Height503
EyesBROWN
HairBROWN
RaceH
SexF
DOBINDIVIDUAL
UNIT
Non Motorist
Equipment
Initial Contact Point
11 - LEFT FRONT CORNER
Color
GRY - GRAY
Body Style
UT - SPORT UTILITY VEHICLE
Model
CHEROKEE
MakeJEEP
Year2017
Vehicle Identification Number
3C4NJDBB7HT680020
Country of IssuanceUNITED STATES
StIL
Plate TypeAUT - AUTOMOBILE
License Plate Number
BN52943
Crash Date
08/28/2020
OFFICE USE ONLY
(608) 356-4895
Telephone Number(773) 961-5533 EXT.
Country of ResidenceUNITED STATES
Zip Code61618
StIL
CityCHICAGO
PO Box Street Address2 Street Address4038 N WHIPPLE ST
Date of Birth Suffix Middle First NameALEXIS
Last NameACEVEDO
Company Name Organization TypeINDIVIDUAL
Use Operator Address
Vehicle Owner Same As Operator
Driver Actions
IMPROPER OVERTAKING / PASSING RIGHT
Bus Use Driver Prior Action Other
What Driver Was Doing
OVERTAKE RIGHT
Vehicle Removed By
OPERATOR
Vehicle Factors
NOT APPLICABLE
Towed Due To Damage
NOT TOWED
Extent Of DamageFUNCTIONAL DAMAGE
01
01
Vehicle Damage08 LEFT SIDE REAR, 09 LEFT SIDE MIDDLE, 10 LEFT SIDE FRONT, 11
-LEFT FRONT CORNER
UNIT
VEHICLE
Event
MOTOR VEH IN TRANSPORT
01
Event02
Event03
Event04
DescriptionUNSAFE PASSING ON RIGHT
Statute Number
346.08
Issue To?001
UTC NumberBG111156
01
01
Policy Holder Company First Name
ALEXIS
Last NameACEVEDO
Organization TypeINDIVIDUAL
Policy Holder Same As Driver
Policy Holder
Same As Owner
Insurance CompanyALLSTATE-VEHICLE-AND-PROPERTY-INS-CO
HOL
01
UNIT
Truck Bus or HazMat
NO
Road GradeDOWNHILL
Road CurvatureSTRAIGHT
Surface TypeBLACKTOP (BITUMINOUS)
Traffic Control Inoperative/Missing
NO
Traffic Control
NO CONTROL
Traffic Way
TWO-WAY, NOT DIVIDED
Emergency Motor Vehicle Use
NOT APPLICABLE
Special Function
NO SPECIAL FUNCTION
Most Harmful Event: Collision With
MOTOR VEH IN TRANSPORT
Total Lanes
2
Speed Limit55
Pre CrashTire
Mark
Direction Of TravelEASTBOUND
Insurance?YES
Total HazMat Types
0
Total Trailers
0
Total # Citations Issued
0
Train/Bus # Recorded Total Occs4
Operating As Endorsements Vehicle Type(SPORT) UTILITY VEHICLE
Unit Type
AUTOMOBILE
Vehicle Operating As Classification
D CLASS
Unit StatusIN TRANSIT
UNIT
02
02
Unit Summary
Crash Date08/28/2020
OFFICE USE ONLY
(608) 356-4895
Drug & Alcoh
Injury
Drug Type
Drug Test Results Drug Test Type
Drug Test Given
TEST NOT GIVEN
Alcohol Test Results Alcohol Test Type
Alcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
INDIVIDUAL
UNIT
Individual ConditionAPPEARED NORMAL
Action Other Distracted By SourceUNKNOWN
Distracted By ActionUNKNOWN
Action Prior Action To/FromSchool Location Striking Unit #03
Time of Death Date of Death Hospital EMS Run # EMS Agency IdentifierMedicalTransport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICA
Ejected
NOT EJECTED
AirbagNON DEPLOYED
Injury SeverityNO APPARENT INJURY
INDIVIDUAL
UNIT
Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position07 - LEFT
Row01 - FRONT ROW
Safety EquipmentSHOULDER & LAP BELT
On Duty Accident
03
DL Expire Year2021
License StatusVALID LICENSE
License TypeNON-CDL DRIVER'S LICENSE
Country of Issuance
UNITED STATES
License JursidictionSTATE
StateIL
Driver's License Number
Phone Number
(309) 368-9451 EXT.
Weight200
Height602
EyesBLUE
HairBLOND
RaceW
SexM
DOB Country of ResidenceUNITED STATES
Zip Code60156
StateIL
CityLAKE IN THE HILL
PO Box Street Address 2 Street Address
5 LISA CT
Suffix Middle InitialM
First NameDUSTIN
Last NameHARMS
Individual TypeINDIVIDUAL
Use Driver
Address
Citations Issued0
RoleDRIVER
INDIVIDUAL
03
UNIT
02
Non Motorist
Equipment
Country of ResidenceUNITED STATES
Zip Code60156
StateIL
CityLAKE IN THE HILL
PO Box Street Address 2 Street Address
5 LISA CT
Suffix Middle InitialM
First NameSAMANTHA
Last NameHARMS
Individual TypeINDIVIDUAL
Use Driver
Address
Citations Issued0
RolePASSENGER
04
02
Crash Date08/28/2020
OFFICE USE ONLY
(608) 356-4895
Drug & Alcoh
Injury
Drug Type
Drug Test Results Drug Test Type
Drug Test Given
TEST NOT GIVEN
Alcohol Test Results Alcohol Test Type
Alcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
INDIVIDUAL
UNIT
Individual ConditionAPPEARED NORMAL
Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #04
Time of Death Date of Death Hospital EMS Run # EMS Agency IdentifierMedicalTransport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICA
Ejected
NOT EJECTED
AirbagNON DEPLOYED
Injury SeverityPOSSIBLE INJURY
INDIVIDUAL
UNIT
Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position09 - RIGHT
Row01 - FRONT ROW
Safety EquipmentSHOULDER & LAP BELT
On Duty Accident
04
DL Expire Year License StatusVALID LICENSE
License TypeNON-CDL DRIVER'S LICENSE
Country of Issuance
UNITED STATES
License JursidictionSTATE
StateIL
Driver's License Number
Phone Number
(847) 220-0765 EXT.
Weight140
Height505
EyesGREEN
HairBROWN
RaceW
SexF
DOBINDIVIDUAL
UNIT
Non Motorist
Equipment
Country of ResidenceUNITED STATES
Zip Code60156
StateIL
CityLAKE IN THE HILL
PO Box Street Address 2 Street Address
5 LISA CT
Suffix Middle InitialE
First NameBRADLEY
Last NameHARMS
Individual TypeINDIVIDUAL
Use Driver
Address
Citations Issued0
RolePASSENGER
05
02
Crash Date08/28/2020
OFFICE USE ONLY
(608) 356-4895
Drug & Alcoh
Injury
Drug Type
Drug Test Results Drug Test Type
Drug Test Given
TEST NOT GIVEN
Alcohol Test Results Alcohol Test Type
Alcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
INDIVIDUAL
UNIT
Individual ConditionAPPEARED NORMAL
Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #05
Time of Death Date of Death Hospital EMS Run # EMS Agency IdentifierMedicalTransport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICA
Ejected
NOT EJECTED
AirbagNON DEPLOYED
Injury SeverityNO APPARENT INJURY
INDIVIDUAL
UNIT
Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position07 - LEFT
Row02 - SECOND ROW
Safety EquipmentCHILD RESTRAINT SYSTEM - FORWARD FACING
On Duty Accident
05
DL Expire Year License Status License Type Country of Issuance License Jursidiction State Driver's License NumberPhone Number
(309) 368-9451 EXT.
Weight Height Eyes Hair RaceW
SexM
DOBINDIVIDUAL
UNIT
Non Motorist
Equipment
Country of ResidenceUNITED STATES
Zip Code60156
StateIL
CityLAKE IN THE HILL
PO Box Street Address 2 Street Address
5 LISA CT
Suffix Middle Initial First NameISAAC
Last NameHARMS
Individual TypeINDIVIDUAL
Use Driver
Address
Citations Issued0
RolePASSENGER
06
02
Crash Date08/28/2020
OFFICE USE ONLY
(608) 356-4895
Drug & Alcoh
Injury
Drug Type
Drug Test Results Drug Test Type
Drug Test Given
TEST NOT GIVEN
Alcohol Test Results Alcohol Test Type
Alcohol Test Given
TEST NOT GIVEN
Suspected Drug Use
NO
Suspected Alcohol Use
NO
INDIVIDUAL
UNIT
Individual ConditionAPPEARED NORMAL
Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #06
Time of Death Date of Death Hospital EMS Run # EMS Agency IdentifierMedicalTransport
NOT TRANSPORTED
Trapped/Extricated
NOT TRAPPED
Ejection Path
NOT EJECTED/NOT APPLICA
Ejected
NOT EJECTED
AirbagNON DEPLOYED
Injury SeverityNO APPARENT INJURY
INDIVIDUAL
UNIT
Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position09 - RIGHT
Row02 - SECOND ROW
Safety EquipmentCHILD RESTRAINT SYSTEM - REAR FACING
On Duty Accident
06
DL Expire Year License Status License Type Country of Issuance License Jursidiction State Driver's License NumberPhone Number
(309) 368-9451 EXT.
Weight Height Eyes Hair RaceW
SexM
DOBINDIVIDUAL
UNIT
Non Motorist
Equipment
Initial Contact Point
02 - RIGHT SIDE FRONT
Color
WHI - WHITE
Body Style
UT - SPORT UTILITY VEHICLE
Model
ATLAS
MakeVOLKSWAGEN
Year2018
Vehicle Identification Number
1V2MR2CA9JC549122
Country of IssuanceUNITED STATES
StIL
Plate TypeAUT - AUTOMOBILE
License Plate Number
BV73408
Crash Date
08/28/2020
OFFICE USE ONLY
(608) 356-4895
Telephone Number(309) 368-9451 EXT.
Country of ResidenceUNITED STATES
Zip Code60156
StIL
CityLAKE IN THE HILL
PO Box Street Address2 Street Address
5 LISA CT
Date of Birth Suffix MiddleM
First NameSAMANTHA
Last NameHARMS
Company Name Organization TypeINDIVIDUAL
Use Operator Address
Vehicle Owner Same As Operator
Driver Actions
NO CONTRIBUTING ACTION
Bus Use Driver Prior Action Other
What Driver Was Doing
RIGHT TURN
Vehicle Removed By
OPERATOR
Vehicle Factors
NOT APPLICABLE
Towed Due To Damage
NOT TOWED
Extent Of DamageDISABLING DAMAGE
02
02
Vehicle Damage01 - RIGHT FRONT CORNER, 02 - RIGHT SIDE FRONT, 11 - LEFT FRONT
CORNER, 12 - FRONT
UNIT
VEHICLE
EventRIGHT TURN
01
EventMOTOR VEH IN TRANSPORT
02
Event
03
Event
04
Policy Holder Company First Name
SAMANTHA
Last NameHARMS
Organization TypeINDIVIDUAL
Policy Holder Same As Driver
Policy Holder
Same As Owner
Insurance CompanySTATE-FARM-GENERAL-INS-CO
HOL
02
UNIT
Additional Information Photos By Reconstruction By DiagramDescription
Crash Date08/28/2020
OFFICE USE ONLY
(608) 356-4895
NONE
Narrative
UNIT 1 ATTEMPTED TO PASS UNIT 2 ON THE RIGHT SIDE AS UNIT 2 WAS TURNING RIGHT IN TO A DRIVEWAY. UNIT 1 STRUCK UNIT 2 AS IT ATTEMPTED TO PASS. THE DRIVE OF UNIT 1 SAID THE VEHICLE HAD STOPPED AND UNIT 2 WAS NOT USING A TURN SIGNAL. THE DRIVER OF UNIT 2 SAID HE USED HIS TURN SIGNAL AND THAT UNIT 1 WAS DRIVING AT A HIGH RATE OF SPEED.
I, a sworn law enforcement officer, agree that I have not added any CJIS data in this report.
Signature
Law Enforcement Agency Zip Code
53913
LEA State
WI
Law Enforcement Agency City
BARABOO
Law Enforcement Agency Street Address2 Law Enforcement Agency Street Address
1300 LANGE COURT
TAS Agency Name
SAUK COUNTY SHERIFF
Law Enforcement Agency Name
SAUK COUNTY SHERIFFS DEPARTMEN
Law Enforcement Agency type
COUNTY SHERIFF
Law Enforcement Agency Jurisdiction
SAUK
Local Agency Number Officer EMail
Officer Badge Number
9120
DNR Officer ID DOT Officer ID
9120
Suffix Officer Middle Name
J
Officer First Name
KYLE
Officer Last Name
MUELLER
Officer Rank
DEP
Agency Space
Law Enforcement Agency
Crash Date
08/28/2020
OFFICE USE ONLY
(608) 356-4895
TraCS Agency Number
205
BFUNC Agency
5600
ORI Number
WI0570000
Law Enforcement Agency Phone Number
(608) 356-4895 EXT.
Crash Date
08/28/2020