20160402 Hayato LambertAgency Accident Number
AC
C
I
D
E
N
T
#
PO
L
I
C
E
#
Police Number
GE
N
E
R
A
L
I
N
F
O
R
M
A
T
I
O
N
Reportable Accident On Emergency Amended GZDC4V9
DOT Document Number Document Override Number
16040201
16
0
4
0
2
0
1
04/02/2016
4 - Accident Date
0636
5 - Time of Accident (Military Time)
02
6 - Total Units
02
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County LENROOT - 08, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
063
14 - On Hwy No.
NB
14 - On Street Name 14 - Bus/Frnt/Rmp
300 FT15 - Est. Distance NORTH15 - Hwy. Dir
6316 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number 12 - Latitude 13 - Longitude
MOTOR VEHICLE IN TRANSPORT80 - First Harmful Event HEAD ON93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
113 - Road Curvature
HILL
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
DAWN114 - Light Condition SNOW/SLUSH116 - Road Surface Condition SNOW118 - 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
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
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
MN
30 - State
2017
31 - Expiration Year 34 - On Duty Accident
HAYATO
25 - Operator/Pedestrian Last Name
MUSTFA
25 - First Name
C
25 - Middle Initial 25 - Suffix
01/10/
32 - Date Of Birth
MALE
33 - Sex
26 - PO Box
BROOKLYN PARK
27 - City
MN
27 - State
55429
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
C - POSSIBLE 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 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 GZDC4V9 1 5
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
997NJW
56 - License Plate Number
AUT57 - Plate Type MN
58 - State
2017
59 - Exp Year
17530
55 - Vehicle Identification Number
2013
50 - Year
VOLK
51 - Make
SWJTD
52 - Model
4D - 4DR
53 - Body Style
BLK
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT
94 - Vehicle Damage
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
HAYATO
46 - Vehicle Owner Last Name
MUSTFA
46 - First Name
C
46 - Middle Initial 46 - Suffix
01/10
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
BROOKLYN PARK48 - City MN48 - State 5542948 - Zip Code 49 - Telephone Number
AMERICAN-FAMILY-HOME-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
HAYATO
61 - Policy Holder Last Name
MUSTFA
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
L
29 - Driver's License Number
WI
30 - State
2024
31 - Expiration Year 34 - On Duty Accident
LAMBERT
25 - Operator/Pedestrian Last Name
IAN
25 - First Name
S
25 - Middle Initial 25 - Suffix
01/21/1
32 - Date Of Birth
MALE
33 - Sex
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDC4V9 2 525
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
IN
S
26 - Address Street & Number 26 - PO Box
HAYWARD
27 - City
WI
27 - State
54843
27 - Zip Code
T.
28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
40 - Safety Equipment
B - NON-INCAPACITATING 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
91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
399WWU
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
1162
55 - Vehicle Identification Number
1997
50 - Year
GEO
51 - Make
PRIZM
52 - Model
2D - 2DR
53 - Body Style
MAR
54 - Color 100 - Skidmarks to Impact (Ft)
MIDDLE PASSENGER SIDE, FRONT PASSENGER SIDE
94 - Vehicle Damage
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
LAMBERT
46 - Vehicle Owner Last Name
IAN
46 - First Name
S
46 - Middle Initial 46 - Suffix
01/21/1
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code .49 - Telephone Number
USAA-CASUALTY-INS-CO63 - Liability Insurance Company Policy Holder Same As Owner60
LAMBERT
61 - Policy Holder Last Name
IAN
61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDC4V9 3 5
School Bus
02
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Trailer
01
TR
L
106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
105 - Photos By
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
DEPUTY NELSON
ON 04-02-16 AT 0636 DEPUTY NELSON WAS DISPATCHED TO A TWO CAR ACCIDENT ON USH 63 JUST NORTH OF NELSON LAKE RD. DISPATCH ADVISED THAT THE WAS ROAD BLOCKAGE AND INJURE. DEPUTY NELSON ARRIVED ONSCENE WITH DEPUTY DEPEW.
DEPUTY NELSON PARKED ON THE NORTH SIDE OF THE ACCIDENT AND DEPUTY DEPEW PARKED ON THE SOUTH SIDE OF THE
ACCIDENT FOR TRAFFIC CONTROL. DEPUTY NELSON MADE CONTACT WITH THE DRIVER OF UNIT 2 WHO WAS OUT OF THE
VEHICLE STANDING UP ON THE ROAD. DEPUTY NELSON OBSERVED THAT LAMBERT HEAD A LARG CUT ON HIS HEAD NUT DID NOT
HAVE ANY OTHER INJURIES FROM THE ACCIDENT. LAMBERT ADVISED DEPUTY NELSON THAT HE WAS HEADING NORTH ON USH
63 WHEN HE LOST CONTROL AND WENT INTO THE SOUTH BOND LANE. LAMBERT ADVISED THAT HE WAS UNABLE TO CONTROL HIS VEHICLE DUE TO THE ROAD CONDITIONS. IT SHOULD BE NOTED THAT THE IT WAS SNOWING HARD WHICH MADE THE ROADS
VERY SLIPPER. LAMBERT WAS THEN ATTENDED TO BY EMS. DEPUTY NELSON MADE CONTACT WITH THE DRIVER OF UNIT 1 WHO
WAS STILL SITTING IN HIS CAR. HAYATO ADVISED DEPUTY NELSON THAT HE WAS HEADED SOUTH ON USH 63 WHEN UNIT 2 CAME
INTO HIS LANE. HAYATO AND LAMBERT WERE BOTH TRANSPORTED TO THE HAYWARD AREA MEMORIAL HOSPITAL. DEPUTY
NELSON TOOK PICTURES OF THE ACCIDENT SCENE AND ALSO THE DAMAGE TO BOTH VEHICLES. THE TWO VEHICLES WERE
TOWED FROM THE SCENE BY TOW TRUCKS. END OF REPORT.
ON 04-02-16 AT 0636 DEPUTY NELSON WAS DISPATCHED TO A TWO CAR ACCIDENT ON USH 63 JUST NORTH OF NELSON LAKE RD. DISPATCH ADVISED THAT THE WAS ROAD BLOCKAGE AND INJURE. DEPUTY NELSON ARRIVED ONSCENE WITH DEPUTY DEPEW.
DEPUTY NELSON PARKED ON THE NORTH SIDE OF THE ACCIDENT AND DEPUTY DEPEW PARKED ON THE SOUTH SIDE OF THE
ACCIDENT FOR TRAFFIC CONTROL. DEPUTY NELSON MADE CONTACT WITH THE DRIVER OF UNIT 2 WHO WAS OUT OF THE
VEHICLE STANDING UP ON THE ROAD. DEPUTY NELSON OBSERVED THAT LAMBERT HEAD A LARG CUT ON HIS HEAD NUT DID NOT
HAVE ANY OTHER INJURIES FROM THE ACCIDENT. LAMBERT ADVISED DEPUTY NELSON THAT HE WAS HEADING NORTH ON USH
63 WHEN HE LOST CONTROL AND WENT INTO THE SOUTH BOND LANE. LAMBERT ADVISED THAT HE WAS UNABLE TO CONTROL HIS VEHICLE DUE TO THE ROAD CONDITIONS. IT SHOULD BE NOTED THAT THE IT WAS SNOWING HARD WHICH MADE THE ROADS
VERY SLIPPER. LAMBERT WAS THEN ATTENDED TO BY EMS. DEPUTY NELSON MADE CONTACT WITH THE DRIVER OF UNIT 1 WHO
WAS STILL SITTING IN HIS CAR. HAYATO ADVISED DEPUTY NELSON THAT HE WAS HEADED SOUTH ON USH 63 WHEN UNIT 2 CAME
INTO HIS LANE. HAYATO AND LAMBERT WERE BOTH TRANSPORTED TO THE HAYWARD AREA MEMORIAL HOSPITAL. DEPUTY
NELSON TOOK PICTURES OF THE ACCIDENT SCENE AND ALSO THE DAMAGE TO BOTH VEHICLES. THE TWO VEHICLES WERE
TOWED FROM THE SCENE BY TOW TRUCKS. END OF REPORT.
Officer Information
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDC4V9 4 5
OF
F
I
C
E
R
I
N
F
O
R
M
A
T
I
O
N
125 - First Name 125 - Middle Initial
NELSON
125 - Officer Last Name
DENNIS 382
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
04/02/2016
132 - Date Notified 0637133 - Time Notified (Military Time)0644134 - Time Arrived (Military Time)
04/10/2016
135 - Date Of Report
16040201 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDC4V9 5 5