Accident Report – Village of Holmen

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Office: (608) 526-4212
Dispatch: (608) 785-5942
Emergencies: 911
Fax: (608) 526-6944
hpd@holmenwi.gov
119 Wall St W
Holmen, WI 54636
Office Hours:
Monday – Friday
8:00 AM to 4:30 PM
After hours call dispatch
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Do not use email to notify the police department of your urgent complaints or concerns as email is not always checked regularly.

Fill in the information in the first section which provides details on the accident report that you are requesting then fill in the form below and press submit.

If you are requesting additional information (witness statements, video, photos, if any are available) you will need to complete the second form labeled “Request for Access to Public Information” and submit with the first form.

"*" indicates required fields

Information Needed to Request an Accident Report

In order to request an accident report from the Holmen Police Department certain information is required. The more information that you provide the easier it is to process your request. Below there are several fields that should be filled out to the best of your ability. Once you have provided us with as much information on the accident as possible please complete the form and type your full name in the space indicated. Press the submit button at the end of the form and an email will automatically generate and be forwarded to the Law Enforcement Specialist who oversees Accident Reports. Filling out the form and providing the required information will result in the provision of a basic accident report.

If you are requesting additional documents including but not limited to photos (if available), video (if available) witness statements (if available), etc. then you must complete an addition form "Request for Access to Public Records". This additional form is available below.

If you are requesting an Incident Report you must complete the "Request for Access to Public Records" form and hit the submit button. This will result in an email being automatically generated and submitted to the Law Enforcement Specialist who overseas Incident Reports.

Case Number

Date of the Accident*

Location of Accident

Full Name(s) and Date(s) of Birth of Those Involved*

Limited Vehicle/Driver Record Information Request

Name of Person Requesting Report

First Last

Firm/Corporation

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Date of Request*

Type of Incident*

Name of Person About Whom Record(s) are Requested*

Reason for request of particular items of "personal information" or"highly restricted personal information"

Under Wisconsin law a request for access to a public record "is deemed sufficient if it reasonably describes the requested record of the information requested. However, "a request for a record without a reasonable limitation as to subject matter of length of time represented by the record does not constitute a sufficient request." (See State Statute 19.35(1)(h)) I/We are authorized under the Federal Driver's Privacy Protection Act to obtain the identified accident/incident report and personal information based upon the following:

Please Check All That Apply (at least one):

I am requesting a copy of my own record

I am a parent or legal guardian of a minor child and I am requesting a copy of their record

I am requesting the record of another person and have attached their written and noterized consent

A government agency or employed by such , for the purposes of the government agency to carry out its official functions

A federal, state, circuit, local or tribal court, or employed by such , for the purposes of the court to carry out its official functions

A wisconsin or out-of-state law enforcement agency, or employed by such, for the purposes of the law enforcement agency to carry out its functions

Or if below applies

Authorized for use in connection with any civil, criminal , administrative, or arbitral proceedings in any federal, state, circuit, local, or tribal court or agency, or before any self-regulatory body, includcing the service of process, investigation in anticipation of litigation, and the execution of enforcement of judgments and order, or pursuant to an order of a federal, state, circuit, local or tribal court.

Client Name if Above Applies

If one of the following applies

Claims Investigation

Anti-Fraud Activities

Rating or Underwriting

Client Name if Above Applies

Additional Options

Authorized for use in providing notice to the owners of towed or impounded vehicles

Authroized representative or owner of a licensed private investigative agency or licensed security service and the vehilce/driving record being requested for the use of purposes permited under the Federal Driver''s Privacy Protection Act

Authorized as an employer, or its agent of insurer for use in obtaining or verifying information relating to a holder of a commercial driver license (CDL)

Authorized representative or owner of a private toll transportation facility for use in the operation of the facility

For any other use specifically authorized under the law of the State that holds the record, if such use is related to the operation of a motor vehicle or public safety

If Below Applies

Authorized for use in research activities and producing statistical reports, as long as the personal information is not published, re-disclosed or used to contact individuals

If above applies, please provide date range and kind/ nature of information requested in the space provided

The Driver Privacy Protection Act (DPPA) is enforced by the U.S. Department of Justice, which may seek civil and criminal penalties for improperly obtaining, disclosing , or using personal information form a motor vehicle. or public safety or for other use as identified above

I agree that the use of the records I have requested is specifically authorized under the laws fo the State of Wisconsin and the DPPA and that my intended use of the records is related to the operation of a motor vehicle or public safety or for other use as identified above.

I certify that the information and statements on this request are true and correct and understand that the unauthorized disclosure of information obtained from these records for a purpose other than stated on this request form , or the sale of other distribution of the information to a person or organization not disclosed in this request, may result in civil and criminal penalties imposed under Title 18 U.S.C. Section 2724

I further understand that I have the right to request a mandamus review of the responses provided to this request under Wisconsin Statute Section 19.37(1)

Please Enter Your Full Name