CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 JUN 21 AMII: 50
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2).
3.READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Progressive Select Insurance Company A/S/O RAMIREZ, GUILLERMO (...
FULL NAME -
DATE OF BIRTH
-
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. -
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 09-30-20 TIME: 5:24 PM • AM XI PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks. 380 N LINDEN AVE IN RIALTO, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
OUR INSURED WAS TRAVELING AT 380 N LINDEN AVE IN RIALTO, CA WHEN A CITY POLICE VEHICLE WITH PLATE # AL55F89 OPERATERD BY RAMIREZ, CARLOS ALBERTO STRUCK OUR INSURED'S VEHICLE. WE ARE SEEKING REIMBURSEMNT FOR OUR INSURED'S VEHICLE DAMAGES.
4. WERE POLICE AT THE SCENE? X YES • NO WERE PARAMEDICS AT THE SCENE? • YES * NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
RAMIREZ, CARLOS ALBERTO STRUCK OUR INSURED'S VEHICLE
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_$1,500.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $_
Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $. $1,500.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $.
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ $1,500.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L - TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME: _
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE:
DATE: TIME: •AM • PM DATE: _ TIME: _ •AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street corners.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X".
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
CITY CLERN RECETVEL 202A1: CITY OF RIALTO
PARKWAY
SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
MATTHEW HAYWARD 6/14/2022
TYPE OR PRINT NAME DATE
Progressive Select Insurance Company SUBROGATION SPECIALIST
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376
PROGRESSIVE
Payment Address Document Address
24344 Network Place P.O. Box 94639
Chicago, IL 60673-1243 Cleveland, Ohio 44101-9908
Phone: (877)818-0139
Fax: (888) 781-6947
6/14/20222:59:00 PM
Certified Mail 9489 0090 0027 6274 0697 56 Return Receipt Requested
CITY OF RIALTO
CITY CLERK'S OFFICE
150 S. PALM AVE.
RIALTO, CA 92376
RECEIVED 2022 JUN 21 AMII: 50 CITY OF RIALTO
Your Client: RAMIREZ, CARLOS ALBERTO CITY CLERK
Your Claim Number: 3008763
Our Insured: RAMIREZ, GUILLERMO
Our Claim Number: 20-4572786
Amount Subject to Reimbursement: $1,500.00
Amount of Insured's Deductible: N/A
Please take this as formal notice of our subrogation rights relative to the above -captioned claim. We have completed our investigation into the facts of the above-captioned loss and find that your insured was the proximate cause of the accident.
Location of Loss: 380 N LINDEN AVE IN RIALTO, CA
Date and Time of Loss: 09-30-20 AT 5:24 PM
Description of Loss: OUR INSURED WAS TRAVELING AT 380 N LINDEN AVE IN RIALTO, CA WHEN A CITY POLICE VEHICLE WITH PLATE # OPERATERD BY RAMIREZ, CARLOS ALBERTO STRUCK OUR INSURED'S VEHICLE. WE ARE SEEKING REIMBURSEMNT FOR OUR INSURED'S VEHICLE DAMAGES.
Please make your draft payable to Progressive Select Insurance Company as subrogee of "RAMIREZ, GUILLERMO" , in the amount stated above and mail it to the attention of the undersigned at your earliest convenience.
All supporting documentation is enclosed. Thank you for your anticipated, prompt attention to this matter.
Progressive Subrogation
Progressive Select Insurance Company
Tel. 877-818-0139
Fax. 888-781-6947
[email protected]
W-9 Request for Taxpayer
Form Give Form to the
(Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS.
Internal Revenue Service • Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name (as shown on your income tax retum). Name is required on this line; do not leave this line blank.
PROGRESSIVE SELECT INSURANCE COMPANY
2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; see instructions on page 3):
Individual/sole proprietor or C Corporation Ls Corporation • Partnership •Trust/estate single-member LLC 5
Exempt payee code (if any) _
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) • Print or type. See Specific Instructions on page 3. Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting LLC If the LLC is classified as a single-member LL that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that code (if any) is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions) P (Applies to accounts maintained cutside the U.S.) 5 Address (number, street, and apt, or suite no.) See instructions. Requester's name and address (optional) 6 City, state, and ZIP code
MAYFIELD VILLAGE, OH 44143
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. 5 9 - 3 2 3 8 1 5
Part I| Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or l am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that l am no longer subject to backup withholding; and
3.1 am a U.S. citizen or other U,S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum. For real estate transactions, item 2 does not apply. For mortgage interest paid acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part Il, later.
Sign Signature of
Here U.S. person P Date P тиму ", 0020
• Form 1099-DIV (dividend cluding those from stocks or mutual General Instructions
funds)
Section references are to the Internal Revenue Code unless otherwise • For 1099-MISC (various types of income, prizes, awards, or gross noted. proceeds)
Future developments, For the latest information about developments • Form 1099-B (stock or mutual fund sales and certain other related to Form W-9 and its instructions, such as legislation enacted transactions by brokers) after they were published, go to www.irs.gov/FormW9.
• Form 1099-S (proceeds from real estate transactions)
Purpose of Form • Form 1099-K (merchant card and third party network transactions) An individual or entity (Form W-9 requester) who is required to file an • Form 1098 (home mortgage interest), 1098-E (student loan interest), information return with the IRS must obtain your correct taxpayer 1098-T (tuition) identification number (TIN) which may be your social security number • For 1099-C (canceled debt) (SSN), individual taxpayer identification number (ITIN), adoption • Form 1099-A (acquisition or abandonment of secured property) taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other Use Form W-9 only if you are a U.S. person (including a resident amount repartable on an information return. Examples of information alien), to provide your correct TIN. returns include, but are not limited to, the following. If you do not retum Form W-9 to the requester with a TIN, you might • Form 1099-INT (interest earned or paid) be subject to backup withholding. See What is backup withholding, later.
Cat. No. 10231X For W-9 (Rev. 10-2018)
Claim Payment Detail Page 1 of 1
Claim Payment Detail (20-4572786 )
- Payment Information
Disbursement Number: 501128595 Total Amount: $1,500.00
Digital Payment#: 11120424 Invoice Number: 80232050
Pay to the Order of: GUILLERMO A RAMIREZ
Digital Payment
Notification Method: Email:
Phone Number:
In Payment Of: Progressive Invoice Number: 80232050
- Reviewed Summary
Issuing Rep: A105275 Approved By:
Issue Date: 02-12-21 Review Date:
Last Updated Rep: A105275 Reviewed By:
- Bank Information
Type: Loss Bank Code: DGT
Stop Reason: Cleared: 02-14-21
Stop Date:
- Exposure Detail: UM/UIM
Party Name: RAMIREZ, GUILLERMO A Amount Paid: $1,500.00 Payment Type: FINAL PAYMENT Deductible Taken: $0.00
https://claimspayments/Alpha/ClaimsPaymentsWeb/default.aspx?page=ClaimPaymentDet... 6/14/2022 Recorded Interview of: Guillermo Ramirez [SP] = Spelling Claim No.: 204572786 [SS] = Speaking Simultaneously
Date Of Interview: 2/12/2021 [RD] - Recording Damage
Q: Cecelia Donaquez [SP]
A: Guillermo Ramirez
1 [Recording: Recording initiated.]
2 [Recording: Recording initiated.]
5 Q: This is Cecelia Donaquez speaking. Today is February 12t, 2021. I am discussing a 6 settlement of a claim with Guillermo Ramirez arising from an accident that occurred on 7 September 30th, 2020, in the city of Rialto, California, with Tanisha Crawford [SP]. And 8 being handled under the Progressive, uh, Select Insurance Company, policy number 9 938390854. And the claim number 204572786. Uh, Guillermo, can you please confirm 10 your full name and spell your last name?
11 12 A: It's Guillermo Antonio Ramirez. And last name is R-A-M-I-R-E-Z. 13 14 Q: Thank you, and what is your date of birth?
15 16 A: December 23rd , 1995.
17 18 Q: OK, and please confirm your address?
19 20 A:
21 22 Q: Thank you, and do you realize that I'm recording this agreement? 23 24 A: Yes.
25 26 Q: Do I have permission to continue?
27 28 A: Yes.
29 30 Q: Do you agree and understand that I will be sending you a payment in amount of $1,500 31 and that, in which, with this charges all claims being made under your policy for bodily 32 injury sustained by you, which arose out of the ownership or operation of an uninsured 33 automobilist by the name of Tanisha Crawford? And that this settlement of the bodily 34 injury claim includes all liens and wage laws and constitutes the release of your presence 35 and future bodily injury damages resulting from this loss? 36 37 A: Yes.
38 Allegis Transcript ID: 3570961
Recorded Interview of: Guillermo Ramirez [SP] - Spelling Claim No.: 204572786 [SS] = Speaking Simultaneously
Date Ot Interview: 2/12/2021 [RD]= Recording Damage
39 Q: OK, so then I'm gonna go ahead and email you, uh, a link right now so you can get your 40 direct deposit, OK?
41 42 A: OK.
43 44 Q: OK, Guillermo. Take care. Bye-bye.
45 46 A: OK, thank you, you as well.
47 48 Q: Mm-hmm.
Allegis Transcript ID: 3570961
STATE OF CAL FORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC COLLISION REPORT
CHP 555 PAGE 1 (REV. 04-11) OPI 060 PAGE 1 OF 15
SPECIAL CONDITIONS NUMBER HIT & RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER POLONT
COURTESY REPORT wUNeD
ON-DUTY EMERGENCY VEHICLE RIALTO WEST VALLEY 9860-2020-03330
NUMBER KILLED STAREN COUNTY REPORTING DISTRICT DAY OF WEEK TOW AWAY BEAT
MASCEVESNOI
0 SAN BERNARDINO WEDNESDAY YES
NO
MO DAY YEAR TIME (2400) NCIC # OFFICER L.D.
LINDEN AVENUE 09/30/2020 1724
MILEPOST INFORMATION: GPS COORDINATES PHOTOGRAPHS BY: NONE LOCATION LATITUDE 34.105316° LONGITUDE - 117.4009470
AT INTERSECTION WITH: STATE HWY REL
OR: 245 FEET NORTH OF LORRAINE PL YES NO
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE CA 2020 TOYT CAMRY GRY AL.55F89 CA
NAME(FIRST, MIDDLE, LAST) ON DUTY EMERGENCY VEHICLE
CARLOS ALBERTO RAMIREZ OWNER'S NAME • SAME AS DRIVER
PEDES. STREET ADDRESS POLICE DEPT RIALTO
128 N. WILLOW AVENUE OWNER'S ADDRESS
[X SAME AS DRIVER
CITY / STATE / ZIP
VEHICLE
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF:
OFFICER DRIVER OTHER
BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE J&K TOWING - (909)875-0400
CLIST MO DAY YEAR
M BLK BRN 5-10 215 01/10/1976 H PRIOR MECH. DEFECTS X NONE APP. REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: 4TIKZ1AK8LU033485 UNKNOWN (909)820-2550 DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
VEHICLE TYPE
INSURANCE CARRIER POLICY NUMBER UNK NONE
CITY OF RIALTO 48 I MOD MAJOR ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT
CA DOT
S LINDEN AVE 45 MC/M
CAL-T TCP/PSC
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE 2 CA C G 2014 FORD FUSION ORG CA
DRIVER NAME(FIRST, MIDDLE, LAST)
TAMESHA KEYANNA CRAWFORD OWNER'S NAME SAME AS DRIVER
SECES. STREET ADDRESS
OWNER'S ADDRESS SAME AS DRIVER
PARKED CITY / STATE / ZIP
VEHICLE
VICTORVILLE CA 92392 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER OTHER BICY: SEX HAIR EYES | HEIGHT WEIGHT BIRTHDATE RACE J&K TOWING - (909)875-0400
CLIST MO DAY YEAR
F BLK BRN 5-05 133 05/28/1985 B PRIOR MECHANICAL DEFECTS - NONE APP. REFER TO NARRATIVE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE DESCRIBE VEHICLE DAMAGE
VEHICLE TYPE
UNK NONE MINOR
INSURANCE CARRIER POLICY NUMBER
NONE 01 MOD
X MAJOR
DIR OF TRAVEL ON STREET OR HIGHWAY ESPEED LIMIT
CA _ DOT
S LINDEN AVE 45 GAL-T TCP/PSC MC/MX
pARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE 2005 HOND CIVIC BLK CA
3 CA G
DRIVER NAME(FIRST, MIDDLE, LAST)
GUILLERMO ANTONIO RAMIREZ OWNER'S NAME SAME AS DRIVER
STREET ADDRESS
OWNER'S ADDRESS SAME AS DRIVER
CITY / STATE I ZIP
RIALTO CA 92376
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER
SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE J&K TOWING - (909)875-0400
MO DAY YEAR
M BRN BRN 5.11 250 12/23/1995 H PRIOR MECHANCIAL DEFECTS NONE APP. REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
VEHICLE TYPE
DAI
POLICY NUMBER UNK NONE MINOR
INSURANCE CARRIER
PROGRESSIVE 938390854 01 MOD MAJOR ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT DOT
CA
LINDEN AVE 45 CAL-T TCP/PSC MC/MX
PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED MARTEN CARRILLO 020856 " YES • NO NIA
AN INTERNATIONALLY ACCREDITED AGENCY
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC COLLISION REPORT
CHP 555 PAGE 1 (REV. 04-11) OP| 060 PAGE 2 OF 15
SPECIAL CONDITIONS NUMBER HIT & RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER
COURTESY REPORT PLURED FELONY
ON-DUTY EMERGENCY VEHICLE 1 RIALTO WEST VALLEY 9860-2020-03330
NUMBER KILLED HIT & RUN COUNTY REPORTING DISTRICT BEAT DAY OF WEEK TOW AWAY
MISDEMEANOR
0 SAN BERNARDINO WEDNESDAY
YES NO
COLLISION OCCURRED ON: MO DAY YEAR| TIME (2400) NG/G # OFFICER I.D.
LINDEN AVENUE 09/30/2020 1724
MILEPOST INFORMATION: GPS COORDINATES NONE
PHOTOGRAPHS BY:
LOCATION LATITUDE 34.105316° LONGITUDE - 117.4009470
AT INTERSECTION WITH: STATE HWY REL
OR: 245 FEET NORTH OF LORRAINE PL YES - NO
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE 4 2006 HOND CIVIC BL CA
DRIVER NAME(FIRST, MIDOLE, LAST)
OWNER'S NAME SAME AS DRIVER
STREET ADDRESS NANCY MORALES
OWNER'S ADDRESS SAME AS DRIVER
PARKED CITY / STATE / ZIP
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER OTHER BICY. SEX HAIR | HEIGHT WEIGHT BIRTHDATE RACE
PARKED ON SCENE
PRIOR MECH. DEFECTS NONE APP. REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE SHADE IN DAMAGED AREA
INSURANCE CARRIER POLICY NUMBER UNK NONE X MINOR
NONE 01 MOD MAJOR ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT
CA DOT
LINDEN AVE 45
CAL-T TCP/PSC MC/MX
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE 5 DRIVER NAME(FIRST, MIDDLE, LAST)
OWNER'S NAME SAME AS DRIVER
STREET ADDRESS
OWNER'S ADDRESS SAME AS DRIVER
CITY / STATE / ZIP
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER OTHER
SEX HAIR EYES | HEIGHT WEIGHT
PRIOR MECHANICAL DEFECTS NONE APP. REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
UNK NONE MINOR
INSURANCE CARRIER POLICY NUBBER
MOD ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT DOT
CA
CAL-T TCP/PSC MC/M
DRIVER'S LICENSE NUMBER ЗТАТЕ CLASS AIR BAC SAFETY EQUIP. VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE 6 DRIVER NAME(FIRST, MIDDLE, LAST)
OWNER'S NAME SAME AS DRIVER
STREET ADDRESS
OWNER'S ADDRESS SAME AS DRIVER
CITY / STATE / ZIP
DISPOSITION OF VEHICLE ON ORDERS OF: BREWER OTHER
SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE
" CLisT MO YEAR
PRIOR MECHANCIAL DEFECTS NONE APP. REFER TO NARRATIVE
HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
POLICY NUMBER UNK NONE MINOR
INSURANCE CARRIER
MOD MOOR 7 ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT
CAL.T TCP/PSC MC/MX
PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED MARTEN CARRILLO 020856 N/A
EYES • NO
AN INTERNATIONALLY ACCREDITED AGENCY
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC COLLISION CODING
CHP 555 CARS PAGE2 (REV. 04-11) OPI 060 PAGE 3 OF 15
DATE OF COLLISION (MO. DAY YEAR) TIME(2400) NGIC * OFFICER I.D NUMBER 09/30/2020 1724 9860-2020-03330
OWNER'S NAME OWNER ADDRESS NOTIFIED
PROPERTY
DAMAGE DESCRIPTION OF DAMAGE
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES
OCCUPANTS CHILD RESTRAINT B - UNKNOWN
A - CELL PHONE HANDHELD
A - NONE IN VEHICLE Q - IN VEHICLE USED L - AIR BAG DEPLOYED
B - UNKNOWN R - IN VEHICLE NOT USED M - AIR BAG NOT DEPLOYED B - CELL PHONE HANDSFREE
C - ELECTRONIC EQUIPMENT
C - LAP BELT USED S - IN VEHICLE USE UNKNOWN N - OTHER
T - IN VEHICLE IMPROPER USE D - RADIO / CD
D - LAP BELT NOT USED P - NOT REQUIRED E - SMOKING
1 - DRIVER
1 2 E - SHOULDER HARNESS USED U - NONE IN VEHICLE
2 TO 6 - PASSENGERS F - EATING
4 5 F - SHOULDER HARNESS NOT USED EJECTED FROM VEHICLE
6 7 - STATION WAGON REAR G- CHILDREN
G - LAP/SHOULDER HARNESS USED M / C BICYCLE HELMET
8 - REAR. OCC TRK OR VAN 0 - NOT EJECTED H - ANIMALS
H - LAP/SHOULDER HARNESS NOT USED
9-POSITION UNKNOWN DRIVER PASSENGER 1 - FULLY EJECTED 1- PERSONAL HYGIENE
J - PASSIVE RESTRAINT USED V - NO X - NO
7 0- OTHER 2 - PARTIALLY EJECTED J- READING
K - PASSIVE RESTRAINT NOT USED W- YES Y - YES K- OTHER
P - NOT REQUIRED 3 - UNKNOWN
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR MOVEMENT PRECEDING
TRAFFIC CONTROL DEVICES 1 2 3 SPECIAL INFORMATION 12/3 COLLISION LIST NUMBER (#) OF PARTY AT FAULT
VC SECTION VIOLATED CITED VE A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED A 22106 B PROCEEDING STRAIGHT
B CONTROLS NOT FUNCTIONING* B CELL PHONE HANDHELD IN USE x. X
B OTHER IMPROPER DRIVING C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD xID NO CONTROLS PRESENT /FACTOR" D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN* A HEAD - ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN X B SIDE SWIPE G 32 FT TRAILER COMBO G BACKING
C REAR END H H SLOWING / STOPPING
WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE T PASSING OTHER VEHICLE
X A CLEAR E HIT OBJECT J J CHANGING LANES
B CLOUDY F OVERTURNED K PARKING MANEUVER
C RAINING G VEHICLE / PEDESTRIAN L L ENTERING TRAFFIC
D SNOWING H OTHER: M M OTHER UNSAFE TURNING
E FOG / VISIBILITY FT. N XING INTO OPPOSING LANE
F OTHER " MOTOR VEHICLE INVOLVED WITH O PARKED
G WIND A NON - COLLISION P MERGING
LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY
X A DAYLIGHT C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS R OTHER* 12 3
B DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS)
C DARK - STREET LIGHTS E PARKED MOTOR VEHICLE VC SECTION VIOLATED CITED
D DARK - NO STREET LIGHTS F TRAIN
E DARK - STREET LIGHTS NOT G BICYCLE VE SECTION VIOLATED CITED YES FUNCTIONING* H ANIMAL: SOBRIETY - DRUG
ROADWAY SURFACE VC SECTION VIOLATED CITED YES PHYSICAL
1 2 (MARK 1 TO 2 ITEMS)
A DRY I FIXED OBJECT.
B WET xxX A HAD NOT BEEN DRINKING
C SNOWY - ICY J OTHER OBJECT E VISION OBSCUREMENT: B HBD - UNDER INFLUENCE D SLIPPERY (MUDDY, OILY, ETC.) F INATTENTION* C HBD - NOT UNDER INFLUENCE* ROADWAY CONDITION(S) G STOP & GO TRAFFIC D HED - IMPAIRMENT UNKNOWN* (MARK 1 TO 2 ITEMS) PEDESTRIAN'S ACTIONS H ENTERING / LEAVING RAMP E UNDER DRUG INFLUENCE* A HOLES. DEEP RUT X A NO PEDESTRIANS INVOLVED PREVIOUS COLLISION F IMPAIRMENT - PHYSICAL* B LOOSE MATERIAL ON ROADWAY* J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN
B CROSSING IN CROSSWALK -
C OBSTRUCTION ON ROADWAY* AT INTERSECTION K DEFECTIVE VEH. EQUIP.: CITED H NOT APPLICABLE D CONSTRUCTION - REPAIR ZONE C CROSSING IN CROSSWALK - NOT • YES I SLEEPY / FATIGUED• E REDUCED ROADWAY WIDTH AT INTERSECTION • NO
F FLOODED D CROSSING - NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER*: E IN ROAD - INCLUDES SHOULDER M OTHER*
x H NO UNUSUAL CONDITIONS F NOT IN ROAD x IN NONE APPARENT
G APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE
SKETCH MISCELLANEOUS
FOR SKETCH DIAGRAM, SEE PAGE 6
INDICATE NORTH
AN INTERNATIONALLY ACCREDITED AGENCY
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC COLLISION CODING
CHP 555 CARS PAGE (REV. 04-11) OPI 060 PAGE 4 OF 15
DATE OF COLLISION (MO. DAY YEAR) TIME(240C) NCIC # OFFICER I.D NUMBER 09/30/2020 1724 9860-2020-03330
OWNER'S NAME OWNER ADDRESS NOTIFIED
PROPERTY
LYES LINO
DAMAGE DESCRIPTION OF DAMAGE
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES
OCCUPANTS CHILD RESTRAINT B - UNKNOWN
A - NONE IN VEHICLE Q - IN VEHICLE USED L- AIR BAG DEPLOYED A - CELL PHONE HANDHELD
R - IN VEHICLE NOT USED B - CELL PHONE HANDSFREE
B - UNKNOWN M- AIR BAG NOT DEPLOYED
C - LAP BELT USED S - IN VEHICLE USE UNKNOWN C - ELECTRONIC EQUIPMENT
N - OTHER D - RADIO / CD
D - LAP BELT NOT USED T - IN VEHICLE IMPROPER USE P - NOT REQUIRED 1 2 3 1 - DRIVER E - SMOKING
E - SHOULDER HARNESS USED U - NONE IN VEHICLE
2 TO 6 - PASSENGERS F - EATING
4 5 6 7 - STATION WAGON REAR F - SHOULDER HARNESS NOT USED EJECTED FROM VEHICLE G - CHILDREN
G - LAP/SHOULDER HARNESS USED M / C BICYCLE HELMET
8 - REAR. OCC TRK. OR VAN O - NOT EJECTED H - ANIMALS
H - LAP/SHOULDER HARNESS NOT USED DRIVER
9 - POSITION UNKNOWN PASSENGER 1 - FULLY EJECTED 1- PERSONAL HYGIENE 7 J- PASSIVE RESTRAINT USED V - NO X - NO
0 - OTHER 2 - PARTIALLY EJECTED J- READING
K - PASSIVE RESTRAINT NOT USED W- YES Y - YES
3 - UNKNOWN K- OTHER
P • NOT REQUIRED
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR MOVEMENT PRECEDING
LIST NUMBER (#) OF PARTY AT FAULT TRAFFIC CONTROL DEVICES 45 6 SPECIAL INFORMATION 456
COLLISION
VC SECTION VIOLATED: CITED LIVES A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED A 22106 B CONTROLS NOT FUNCTIONING* B CELL PHONE HANDHELD IN USE B PROCEEDING STRAIGHT
B OTHER IMPROPER DRIVING C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD x D NO CONTROLS PRESENT / FACTOR" D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN* A HEAD - ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN B SIDE SWIPE G 32 FT TRAILER COMBO G BACKING
C REAR END H H SLOWING / STOPPING
WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE PASSING OTHER VEHICLE
A CLEAR E HIT OBJECT J CHANGING LANES
B CLOUDY F OVERTURNED K PARKING MANEUVER
C RAINING G VEHICLE / PEDESTRIAN L ENTERING TRAFFIC
D SNOWING H OTHER': M M OTHER UNSAFE TURNING
E FOG / VISIBILITY FT N XING INTO OPPOSING LANE
F OTHER:• MOTOR VEHICLE INVOLVED WITH O PARKED
G WIND A NON - COLLISION P MERGING
LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY
X A DAYLIGHT C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS R OTHER* B DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY 4 5 6 (MARK 1 TO 2 ITEMS) C DARK - STREET LIGHTS E PARKED MOTOR VEHICLE VC SECTION VIOLATED CITED • YES
D DARK - NO STREET LIGHTS F TRAIN
= DARK - STREET LIGHTS NOT G BICYCLE VC SECTION VIOLATED CITED | YES FUNCTIONING*
H ANIMAL •NO SOBRIETY - DRUG
ROADWAY SURFACE VC SECTION VIOLATED CITED EYES PHYSICAL 4 5 6
I A DRY I FIXED OBJECT. (MARK 1 TO 2 ITEMS)
X
B WET A HAD NOT BEEN DRINKING
C SNOWY - ICY , OTHER OBJECT: E VISION OBSCUREMENT: B HBD - UNDER INFLUENCE D SLIPPERY (MUDDY, OILY, ETC.) F INATTENTION C HBD - NOT UNDER INFLUENCE* ROADWAY CONDITION(S) G STOP & GO TRAFFIC D HBD - IMPAIRMENT UNKNOWN* (MARK 1 TO 2 ITEMS) PEDESTRIAN'S ACTIONS H ENTERING / LEAVING RAMP E UNDER DRUG INFLUENCE* A HOLES. DEEP RUT X A NO PEDESTRIANS INVOLVED / PREVIOUS COLLISION [F IMPAIRMENT - PHYSICAL* B LOOSE MATERIAL ON ROADWAY• B CROSSING IN CROSSWALK - J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY* AT INTERSECTION K DEFECTIVE VEH. EQUIP CITED x H NOT APPLICABLE D CONSTRUCTION - REPAIR ZONE C CROSSING IN CROSSWALK - NOT | SLEEPY / FATIGUED• E REDUCED ROADWAY WIDTH AT INTERSECTION • NO
F FLOODED* D CROSSING - NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER* E IN ROAD - INCLUDES SHOULDER M OTHER:
x H NO UNUSUAL CONDITIONS F NOT IN ROAD N NONE APPARENT
G APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE
SKETCH MISCELLANEOUS
FOR SKETCH DIAGRAM, SEE PAGE 6
INDICATE NORTH
AN INTERNATIONALLY ACCREDITED AGENCY
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
INJURED / WITNESSES / PASSENGERS** PAGE 5
CHP 555 CARS PAGE 3 (REV 11-16) OPI 060 OF 15
DATE OF COLLISION (MO DAY YEAR) TIME(2400) NCIC # OFFICER I.D. NUMBER 09/30/2020 1724 9860-2020-03330
WITNESS PASSENGER AGE SEX EXTENT OF INJURY('X' ONE) INJURED WAS ('X' ONE)
PARTY SEAT AIR SAFETY EJECTED
ONLY ONLY NUMBER POS. BAG EQUIP
FATAL SUSPECTED SERIOUS SUSPECTED MINOR POSSIBLE
DRIVER PASS PED. BICYCLIST OTHER
INJURY INJURY INJURY INJURY
# 35 F
2 1 L G 0
NAME / D.O.B. / ADDRESS TELEPHONE
TAMESHA KEYANNA CRAWFORD(05/28/1985) 13199 AURORA AVE VICTORVILLE CA 92392 (909)636-1039 (INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER TAKEN TO:
NOT TRANSPORTED WILL SEEK OWN AID
DESCRIBE INJURIES: LACERATION TO LEFT ARM/ COMPLAINT OF PAIN TO LEGS
VICTIM OF VIOLENT CRIME NOTIFIED
#
NAME / D.O.B./ ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
NAME / D.O.B. / ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
NAME / D.O.B. / ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
NAME / D.O.B./ ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
#
NAME / D.O.B./ ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
PREPARER'S NAME I.D. NUMBER MO. DAY YEAR REVIEWER'S NAME MO DAY YEAR MARTEN CARRILLO 09/30/2020
AN INTERNATIONALLY ACCREDITED AGENCY
STATE OF CALIFORNIA
SKETCH DIAGRAM
CHP 555 Page 4/ Rev. 04-11) OPI 060 PAGE 6 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE= LINDEN
AVENUE
-19 FT.- -19 FT.-
N-1 S-1
ASPHALT
ROADWAY
LORRAINE
PLACE
V-3
V-4
V-2
V-1
V-2
- DOUBLE PAINTED YELLOW LINES
CONCRETE CURB - CONCRETE CURB
PREPARED BY 1.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
FACTUAL DIAGRAM
CHP 555 Page 4(Rev. 04-11) OPI 060 PAGE 7 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE= LINDEN
AVENUE
-19 ft.- - 19 ft.-
N-1 S-1
ASPHALT
ROADWAY
LORRAINE
PLACE
TV-4
- DOUBLE PAINTED YELLOW LINES
CONCRETE CURB -CONCRETE CURB
PREPARED BY 1.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 8 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER ID. NUMBER
09/30/2020 1724 9860-2020-03330
1 FACTUAL DIAGRAM:
2 VEHICLE LOCATION:
3 4 Vehicle # 1's left front tire was located approximately 225 feet north of the north roadway edge 5 prolongation of Lorraine Place and approximately 11 feet east of the west road edge of Linden 6 Avenue.
7 8 Vehicle # 1's left rear tire was located approximately 234 feet north of the north roadway edge 9 prolongation of Lorraine Place and approximately 11 feet east of the west road edge of Linden 10 Avenue.
11 12 Vehicle # 2's left front tire was located approximately 174 feet north of the north roadway edge 13 prolongation of Lorraine Place and approximately 19 feet east of the west road edge of Linden 14 Avenue.
15 16 Vehicle # 2's left rear tire was located approximately 183 feet north of the north roadway edge 17 prolongation of Lorraine Place and approximately 19 feet east of the west road edge of Linden 18 Avenue.
19 20 Vehicle # 3's left front tire was located approximately 220 feet north of the north roadway edge 21 prolongation of Lorraine Place and approximately 23 feet east of the west road edge of Linden 22 Avenue.
23 24 Vehicle # 3's left rear tire was located approximately 211 feet north of the north roadway edge 25 prolongation of Lorraine Place and approximately 23 feet east of the west road edge of Linden 26 Avenue.
27 28
29 PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 9 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
1 FACTUAL DIAGRAM (Continued):
2 VEHICLE LOCATION (Continued):
3 4 Vehicle # 4's left front tire was located approximately 211 feet north of the north roadway edge 5 prolongation of Lorraine Place and approximately 5 feet east of the west road edge of Linden 6 Avenue.
7 8 Vehicle # 4's left rear tire was located approximately 220 feet north of the north roadway edge 9 prolongation of Lorraine Place and approximately 5 feet east of the west road edge of Linden 10 Avenue.
11 12 FACTS:
13 NOTIFICATION:
14 15 On 09/30/2020, at approximately 1756 hours, I received a radio call from Inland CHP Dispatch 16 advising of a four vehicle traffic collision with an ambulance responding, involving Rialto PD that 17 occurred on Linden Avenue, near Foothill Boulevard. I responded from Blake Street and Vermont 18 Street and arrived at approximately 1821 hours. The traffic collision was located on Linden 19 Avenue, north of Lorraine Place. Upon arrival, I determined this to be a four vehicle traffic 20 collision resulting in minor injuries.
21 22 All times, speeds and measurements in this investigation are approximate. Measurements were 23 obtained utilizing a roll meter, visual estimation, and a G.P.S mapping application. 24 25
26 27
28 29
PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 10 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
1 SCENE:
2 3 This collision occurred on Linden Avenue, north of Lorraine Place, within the city limits of Rialto. 4 Linden Avenue is a north/ south designated roadway, constructed of asphalt. At this location, 5 there is one traffic lane for each direction of travel, delineated by solid painted yellow lines. The 6 roadway is bordered to the west by a raised concrete curb. The roadway is bordered to the east 7 by a raised concrete curb. The posted speed limit at this location is 45 miles per hour. There 8 were no visual obstructions noted or claimed. The weather conditions at the time of the collision 9 were warm, dry, and clear. This collision occurred during the hours of daylight. 10 11 PARTIES:
12 13 Party # 1 (P-1, Ramirez) was located at the scene as he was standing next to Vehicle # 1 (V-1, 14 Toyota) on Linden Avenue, north of Lorraine Place. P-1 was positively identified by his valid 15 California driver license as Carlos Alberto Ramirez. P-1 is a sworn peace officer for the Rialto 16 Police Department, and was on-duty, in plain clothing, at the time of the collision. P-1 was placed 17 as the driver of V-1 at the time of the collision by his own statement, his location standing next to 18 V-1 upon my arrival, and he is employed by the registered owner of V-1. 19 20 Vehicle #1 (V-1, Toyota) was located at the scene on its wheels, facing in a southerly direction, 21 partially blocking the southbound lane of Linden Avenue, north of Lorraine Place. V-1 is an 22 authorized emergency vehicle as defined in California Vehicle Code Section 165. V-1 sustained 23 moderate damage which consisted of, but was not limited to the following: Dents and scrapes to 24 left side doors, dented left front fender, and damage to right front bumper. The airbags of V-1 did 25 not deploy as a result of the collision, and no mechanical defects were noted or claimed. 26 27
28 29
PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 11 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
1 PARTIES (Continued):
2 3 Party # (P-2, Crawford) was driven by family members to Arrowhead Regional Medical Center, 4 prior to my arrival. P-2 provided her driver license, registration, and phone number to Rialto PD. 5 P-2 was positively identified by her valid California driver license as Tamesha Keyanna Crawford, 6 with a D.O.B. of 05/28/1985. P-2 was placed as the driver of Vehicle # 2 (V-2, Ford) at the time of 7 the collision by her own statement, her injuries sustained as a result of the collision, and she is the 8 registered owner of V-2.
9 10 Vehicle # 2 (V-2, Ford) was located at the scene on its wheels, facing in a southerly direction, 11 blocking the southbound lane of Linden Avenue, north of Lorraine Place. V-2 sustained major 12 damage which consisted of, but was not limited to the following: Crumpled front bumper, 13 damaged left front fender, broken front axle, crumpled hood, and damaged right front fender. The 14 seatbelts of V-2 were visually inspected and the airbags deployed as a result of the collision. No 15 mechanical defects were noted or claimed.
16 17 Party # 3 (P-3, G. Ramirez) was located and contacted at the scene on the concrete sidewalk. 18 P-3 was positively identified by his valid California driver license as Guillermo Antonio Ramirez, 19 with a D.O.B. of 12/23/1995. P-3 was placed as the driver of Vehicle # 3 (V-3, 2005 Honda) at the 20 time of the collision by his own statement, his location at the scene, and he is the registered owner 21 of V-3.
22 23 Vehicle # 3 (V-3, 2005 Honda) was located at the scene on its wheels, facing in a northerly 24 direction, blocking the northbound lane of Linden Avenue, north of Lorraine Place. V-3 sustained 25 major damage which consisted of, but was not limited to the following: Dents and scrapes to front 26 bumper, damaged left front fender, broken front axle, scrapes and scratches to the driver side 27 door. The airbags of V-3 deployed as a result of the collision, and no mechanical defects were 28 noted or claimed.
29 PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 12 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
1 PARTIES (Continued):
2 3 Vehicle # 4 (V-4, 2006 Honda) was located at the scene, parked on its wheels, facing in a 4 southerly direction, along the west curb edge of Linden Avenue, north of Lorraine Place. V-4 5 sustained minor damage which consisted of, but was not limited to the following: Dents and 6 scrapes to the left side of the rear bumper. The airbags of V-4 did not deploy as a result of the 7 collision, and no mechanical defects were noted or claimed. 8 9 PHYSICAL EVIDENCE:
10 11 Damage to involved vehicles.
12 Refer to Factual Diagram for further information.
13 14 STATEMENTS:
15 16 Party #1 (P-1, Ramirez) was contacted at the scene and he related, in essence, he was stopped 17 in Vehicle # 1 (V-1, Toyota) along the west curb edge of southbound Linden Avenue, north of 18 Lorraine Place, while conducting an operation with the Rialto Police Department. P-1 "pulled out" 19 in V-1 to the left, into the southbound lane of Linden Avenue, and felt an impact to the left side of 20 V-1. The right front of Vehicle # 2 (V-2, Ford) sideswiped the left side of V-1. P-1 related V-2 21 traveled into the northbound lane of Linden Avenue and collided with Vehicle # 3 (V-3, 2005 22 Honda). V-1 continued traveling in a southerly direction and P-1 applied the brakes to V-1, but 23 was unable to stop in time. The right front of V-1 collided with the left rear of Vehicle # 4 24 (V-4, 2006 Honda), which was parked along the west curb edge of Linden Avenue. P-1 related he 25 did not observe V-2 approaching his location prior to the collision. After the collision, P-1 exited 26 V-1 and remained on scene until CHP arrival.
27 28
29 PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 13 OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
1 STATEMENTS (Continued):
2 Party #2-2, Crawford was contacted via telephone on 09/30/2020, at approximately 1923 4 hours. P-2 related, in essence, she was driving Vehicle # 2 (V-2, Ford) southbound on Linden 5 Avenue, north of Lorraine Place, at approximately 20-30 miles per hour. As P-2 was driving, she 6 suddenly observed Vehicle #1 (V-1, Toyota) "come out of nowhere" , directly into her path of 7 travel. P-2 related it appeared V-1 was parked along the curb and pulled out into the southbound 8 lane. P-2 applied the brakes to V-2 and swerved to the left to avoid the collision but was 9 unsuccessful. The left front of V-1 collided with the right front of V-2. V-2 traveled into the 10 northbound lane of Linden Avenue and the left front of V-2 collided with the left front of Vehicle # 3 11 (V-3, 2005 Honda). After the collision, V-2 came to rest on its wheels, facing in a southerly 12 direction, blocking the roadway. P-2 exited V-2 and remained on scene awaiting emergency 13 personnel.
14 15 Party # 3 (P-3, G. Ramirez) was contacted at the scene and he related, in essence, he was 16 driving Vehicle # 3 (V-3, 2005 Honda) northbound on Linden Avenue, north of Lorraine Place, at 17 approximately 15 miles per hour. While driving, P-3 observed Vehicle # 1 (V-1, Toyota) stopped 18 or parked along the west curb edge of southbound Linden Avenue, and observed Vehicle # 2 19 (V-2, Ford) traveling southbound on Linden Avenue, at approximately 30 miles per hour. P-3 20 related "he blinked" and suddenly observed V-2 swerve into the middle of the roadway, toward the 21 front of V-3. P-3 related he was unable to react in time to avoid the collision and the left front of 22 V-2 collided with the left front of V-3. After the collision, V-3 became disabled, on its wheels, 23 facing in a northerly direction, blocking the northbound lane of Linden Avenue. P-3 exited V-3 and 24 awaited emergency personnel. P-3 was unable to provide details regarding V-1 colliding with V-2, 25 or V-1 colliding with Vehicle # 4 (V-4, 2006 Honda). 26 27
28 29
PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 14OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
1 OPINIONS AND CONCLUSIONS:
2 SUMMARY:
3 4 Vehicle # 4 (V-4, 2006 Honda) was parked, unoccupied, facing in a southerly direction along the 5 west curb edge of southbound Linden Avenue, north of Lorraine Place. 6 Party # 3 (P-3, G. Ramirez) was driving Vehicle # 3 (V-3, 2005 Honda) northbound on Linden 7 Avenue, north of Lorraine Place, at approximately 15 miles per hour. Party # 2 (P-2, Crawford) 8 was driving Vehicle # 2 (V-2, Ford) southbound on Linden Avenue, north of Lorraine Place, at 9 approximately 30 miles per hour. Party # 1 (P-1, Ramirez) was stopped in Vehicle # 1 (V-1, 10 Toyota) along the west curb edge of Linden Avenue, north of Lorraine Place. V-1 was to the rear 11 of V-4. V-2 was approaching the left rear of V-1. V-3 was approaching the front of V-4, V-1, and 12 V-2.
13 14 This collision occurred when P-1 accelerated and turned V-1 to the left into the southbound lane of 15 Linden Avenue, directly into the path of V-2. P-2 applied the brakes of V-2 and turned to the left to 16 avoid the collision, but was unsuccessful. The left side of V-1 collided with the right front of V-2. 17 V-2 traveled into the northbound lane of Linden Avenue and the left front of V-2 collided with the 18 left front of V-3. V-1 traveled in a southerly direction and the right front of V-1 collided with the left 19 rear of V-4. After the collision, V-1 came to rest on its wheels, facing in a southerly direction, 20 partially blocking the southbound lane of Linden Avenue. P-1 exited V-1 and awaited CHP arrival. 21 V-2 came to rest on its wheels, facing in a southerly direction, blocking the southbound lane of 22 Linden Avenue. P-2 exited V-2 and awaited emergency personnel. V-3 came to rest, on its 23 wheels, facing in a northerly direction, blocking the northbound lane of Linden Avenue. P-3 exited 24 V-3 and awaited emergency personnel. V-4 came to rest on its wheels, facing in a southerly 25 direction, parked along the west curb edge of Linden Avenue. 26 27
28 29
PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 15OF 15
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
09/30/2020 1724 9860-2020-03330
1 AREAS OF IMPACT (A.O.I.):
2 3 A.O.I. #1 (V-1 vs. V-2) was located approximately 245 feet north of the north roadway edge 4 prolongation of Lorraine Avenue and approximately 7 feet east of the west road edge of Linden 5 Avenue.
6 7 A.O.I. # 2 (V-2 vs. V-3) was located approximately 215 feet north of the north roadway edge 8 prolongation of Lorraine Avenue and approximately 22 feet east of the west road edge of Linden 9 Avenue.
10 11 A.O.I. # 3 (V-1 vs. V-4) was located approximately 220 feet north of the north roadway edge 12 prolongation of Lorraine Avenue and approximately 5 feet east of the west road edge of Linden 13 Avenue.
14 15 CAUSE:
16 17 Party # 1 (P-1, Ramirez) caused this traffic collision by driving Vehicle # 1 (V-1, Toyota) in 18 violation of California Vehicle Code Section 22106- No person shall start a vehicle stopped, 19 standing, or parked on a highway, nor shall any person back a vehicle on a highway until such 20 movement can be made with reasonable safety.
21 22 The Summary, Areas of Impact, and Cause in this traffic collision were established by vehicle 23 damage and statements.
24 25 RECOMMENDATIONS:
26 27 None
28 29
PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
MARTEN CARRILLO 09/30/2020
neopost
Progressive
PO Box 94639 POSTAGE $005.5
U!
Cleveland, OH 44101
ZIP 441
041L 1229
CITY OF RIALTO
2022 JUN 21 AMII: 50
RECEIVEL
CITY CLERA
PROGRESS/L
9489 0090 0027 6274 0697 56
hel 800 PR C
tney Bow