Amount of Policy SWORN STATEMENT Policy Number 025860222 in
Agency Name Alliant Insurance Services
PARTIAL PROOF OF LOSS
Issued Expires
March 31, 2017 March 31, 2018
To Lexington Insurance Company
Boston, Massachusetts
By the above indicated policy of insurance your insured SAC EIA / City of Chula Vista against loss by all risk of physical damage upon the property described, according to the terms and conditions of the said conditions of the said policy and all forms, endorsements, transfers and assignments attached thereto.
1. Time and Origin: A loss occurred about the hour of o'clock M., on the 1$t day of February 20 18.
The cause and origin of said loss were: Vehicle Impact
2. Occupancy: The building described, or containing the property described, was occupied at the time of the loss as follows, and for no other purpose whatever: Elite Athletes Training Center, Chula Vista, CA
3. Title and Interest: When this policy was acquired and at the time of the loss the interest of your insured in the property described therein was sole and unconditional ownership, and no other person or persons had any interest therein or incumbrance thereon. (State exceptions, if any.) NO EXCEPTIONS
4. Changes: Since the said policy was acquired there has been no assignment thereof, or change of ownership, use, occupancy, possession, location or exposure of the property described, or of our insured's interest therein. (State exceptions, if any.)
NO EXCEPTIONS
5. Total Insurance: The total amount of insurance upon the property described by this policy was, at the time of the loss,
6. The Cash Value of said property at the time of loss was ...... $ Not Determined
7. The Whole Loss and Damage was .... $ Not Determined
8. The Amount Claimed under the above numbered policy ........... .....$ 1,015,924.40 The said loss did not originate by any act, design or procurement on the part of your insured, or this affiant; nothing has been done by or with the privity or consent of your insured or this affiant, to violate the conditions of the policy, or render it void; no articles are mentioned herein or in annexed schedules but such as were in the building damaged or destroyed, and belonging to, and in possession of the said insured at the time of said loss; no property saved has in any manner been concealed, and no attempt to deceive the said company, as to the extent of said loss, has in any manner been made. Any other information that may be required will be furnished and considered as part of this proof.
The furnishing of this blank or the preparation of proofs by a representative of the above insurance company is not a waiver of any of their rights.
FOR YOUR PROTECTION, CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM:
Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
State of California Лиль
sured Signature
County of San Diego City of Chula Vista
Insured
Subscribed and sworn to (or affirmed) before me on this з8th day of Apri / (menth), 2022 (year) by Janice allener proved to me on the assisatisfactory evidence to be (signature of Notary)
1cLarens File Nol/002.045053.00
Tower 7
Statement of Loss
CSAC-EIA: City of Chula Vista Preliminary and Subject to Discussion Vista Elite Athletes Training Facility Date of Loss: February 1, 2018 2800 Olympic Parkway Nature of Loss: Truck impact to Pedestrian Bridge Chula Vista, CA File Number: 02.045053.00.A
Category Invoice Date Description Submitted Confirmed Review Comments A) Degenkolb Engineering
Degenkolb Engineers 16446 4/30/2020 Engineering - Bridge Damage 12,390.00 $ 12,390.00 Degenkolb Engineers 16909 5/31/2020 Engineering - Bridge Damage 5,005.00 $ 5,005.00 Degenkolb Engineers 17196 6/30/2020 Engineering - Bridge Damage 3,852.50 $ 3,852.50 Degenkolb Engineers 17940 8/31/2020 Engineering - Bridge Damage 1,240.00 $ 1,240.00 Degenkolb Engineers 18334 9/30/2020 Engineering - Bridge Damage 1,550.00 S 1,550.00 New Degenkolb Engineers 19310 19130 Engineering - Bridge Damage 962.50 $ 962.50 New Total 25,000.00$ 25,000.00$
B) Kimley Horn 14987865 9/30/2019 Consulting Services - Bridge Design $ 10,321.26$ 10,321.26 Kimley-Horn 15360798 11/30/2019 Consulting Services - Bridge Design 4,722.50 4,722.50 Kimley-Horn 151495331 10/31/2019 Consulting Services - Bridge Design 12,147.50 12,147.50 Kimley-Horn 16572084 4/30/2020 Consulting Services - Bridge Design 4,120.00 4,120.00 Kimley-Horn 16689979 5/31/2020 Consulting Services - Bridge Design 6,425.00 6,425.00 Kimley-Horr 17023342 6/30/2020 Consulting Services - Bridge Design 29,940.00 29,940.00 Kimley-Horr 17071286 7/31/2020 Consulting Services - Bridge Design 6,345.00 6,345.00 Kimley-Horn 17426653 Consulting Services - Bridge Design $ 13,777.50$ 13,777.50 17239692 8/31/2020 Consulting Services - Bridge Design $ 4,305.00 $ 4,305.00 17661695 10/31/2020 [Consulting Services - Bridge Design $ 18,608.65 18,608.65 17948360 11/30/2020 Consulting Services - Bridge Design $ 27,726.90 $ 27,726.90 18024430 12/31/2020 Consulting Services - Bridge Design 8,837.00 $ 8,837.00 18306485 1/31/2021 Consulting Services - Bridge Design es es 7,138.30 7,138.30 $
18349480 2/28/2021 Consulting Services - Bridge Design $ 20,602.50 20,602.50 186811112 3/31/2021 Consulting Services - Bridge Design 39,810.30 $ 39,810.30 18846050 4/30/2021 Consulting Services - Bridge Design $ 8,449.00 $ 8,449.00 19038102 5/31/2021 Consulting Services - Bridge Design 22,343.30 22,343.30 19105602 6/30/2021 Consulting Services - Bridge Design $ 45,026.60 45,026.60 19413181 Consulting Services - Bridge Design $ 17,337.95 17,337.95 19653634 8/31/2021 Consulting Services- Bridge Design $ 685.00 685.00 19686652 9/30/2021 Consulting Services - Bridge Design $ 18,372.10 S 18,372.10 20055558 10/31/2021 Consulting Services - Bridge Design $ 4,318.80 $ 4,318.80 Kimley-Horn 20187983 | 11/30/2021 Consulting Services - Bridge Design $ 24,228.95 $ 24,228.95 Statement of Loss Current - Page 1 of 2
Statement of Loss
Kimley-Horn 20445014 12/31/2021 Consulting Services - Bridge Design 7,387.75 $ 7,387.75 Total $ 362,976.86 $ 362,976.86 $
C) Reconstruction Work
Blue Pacific Engineering Contract 3/31/2022 Bridge Reconstruction $ 1,713,727.00 | $ 1,370,981.60 $ 342,745.40 Bid Correction - math error Advance payment 80% bid amount
D) Extra Expense
Tri-Group Construction #1 8/2/2021 Construction of Temporary Guard Shack S 85,882.82 $ 85,882.82 Tri-Group Construction Retention 12/8/2021 Construction of Temporary Guard Shack$ 4,520.15 S 4.520.15 National Security Contract 10/19/2021 Security Equipment 58,363.65 $ 58,363.65 Contract and PO provided $ 148,766.62 $ 148,766.62 $
Chula Vista Employees: July 1, 2018 to October 1, 2020 $ 126,690.12 $ 126,690.12 Salaried Staff not covered per Insurer Chula Vista Employees: October 1, 2020 to January 31, 2021 $ 29,948.50 $ 29,948.50 Salaried Staff not covered per Insurer Total $ 156,638.62 $ $ 156,638.62
Whole Loss ACV & RCV $ 1,907,725.08
Deductible (10,000.00)
Net Claim $ 1,897,725.08
Advance Payment #1 $ (250,000.00) Preliminary Advance - Rpt. 8 Advance Payment #2 $ (400,000.00) Second Advance - Rpt 12 Advance Payment #3 $ (231,800.68) ACV Payment Per MKA revised Est. - Rpt 20 Current Balance $ 1,015,924.40
Statement of Loss Current - Page 2 of 2