SUBROCLAIMS
May 10, 2022
Attn: Rialto City Clerk's Office
City of Rialto Liability
150 S Palm Ave
Rialto, CA 92376
CITY CLERK RECEIVED 2022 MAY 16 AMII: 17 CITY OF RIALTO RE: Your Claim#:
Loss Date: 12/05/2021
Geico Insured: Antonio Suarez Plascencia
Geico Claim#: 0546201880101024
Subro Claims#: 1627887
Dear Rialto City Clerk's Office,
Our office has been retained by Geico Insurance to help expedite payment on the above claim. Geico Insurance had already concluded their investigation of the accident and has found your insured liable for our damages.
Payment for repairs has been made. Documentation is attached. Please honor our claim.
Property Damage: $ 2,455.56
Rental: $ 792.61
Deductible: $ 250.00
Total: $3,498.17
Please make your check payable to Geico and mail it to us at the following address. 28150 N Alma School Parkway #103-642, Scottsdale, AZ 85262 Should you require any assistance in resolving this matter, please contact us at 800-949-5655 x119 or [email protected]. Please refer to the Subro Claims number when calling about this claim.
Sincerely.
Wendy Galleta
On Behalf of Geico
Please be advised that any payment in an amount less than that set forth in this letter that is forwarded to SubroClaims without its prior authorization as described below will not constitute a full and final settlement and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination, unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as "payment in full" or have other words of similar meaning written on them, their processing will not constitute an accord and satisfaction, as SubroClaims/Geico has not agreed to acceptance of such payments. 28150 N Alma School Parkway #103-642, Scottsdale, AZ 85262 Tel: 800) 949-5655 Fax (408) 369-9169 Email:[email protected] https://subroclaims.com
CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2022 MAY 16 AMI: 17
RECEIVED
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 5911.2). CITY CLERK
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code 5911.2)
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: Subro Claims, Inc oloto Geico Ins a/S • Antonio Suarez Plascencia
Unavailable
FULL NAME -
DATE OF BIRTH
Unable to provide
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 28150 N Alma School Road #103-642 Scottsdale, AZ 85262 (800) 949-5655
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Subro Claims, Inc obo Geico Ins a/s/o Antonio Suarez Plascencia
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 28150 N Alma School Road #103-642 Scottsdale, AZ 85262
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 12/05/2021 6:20 TIME: XI AM • PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where apronriate aive street names and addraces, measurements and landmarks.
3. HOW DID DAMAGE OR INJURY OCCUR?
An ambulance reversed into our insured's parked and unoccipied vehicle.
4. WERE POLICE AT THE SCENE? * YES • NO WERE PARAMEDICS AT THE SCENE? •YES X 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.
The driver of the ambulance struck our insured's parked and unoccupied vehicle.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $3,498.17 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: $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $
Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: _ ) TELEPHONE: ( )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: L TELEPHONE: | )
DATE: TIME: •AM • PM
DATE: TIME:
L 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
PARKWAY
SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIEY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Wendy Galleta 05/10/2022
TYPE OR PRINT NAME DATE
behalf f GeiCo TAs
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 COLLISION CENTER OF SAN Workfile ID: 52340e76
BERNARDINO PartsShare: 6y2f4n
Federal ID: 464777075
274 N I St., SAN BERNARDINO, CA 92410 Resale Number: SREH 102-13124 Phone: (909) 453-0933 Federal EPA: CAR000194217
FAX: (909) 614-7778 State EPA: G32801A/N567489
BAR: 279250
Estimate of Record
RO Number: 8738
Written By: Nicole Lutz, 12/9/2021 4:57:59 PM
Adjuster: A71T
Insured: Plascencia, Antonio Policy#: 4413238793
Claim #: 054620188010102401
Type of Loss: Collision Date of Loss: 12/5/2021 6:20 AM Days to Repair: 3
Point of Impact: 08 Left Qtr Post (Left Side)
220
Owner: Inspection Location:
Insurance Company: CITY OF RIALTO
Plascencia, Antonio MB Collision of San Bernardino-XF GEICO 274 NIST 06
Rialto, CA 92376 SN BERNRDNO, CA 92410 IV
Other SAN DIEGO
(909) 453-0933 Day
VEHICLE
2021 TOYO C-HR LE FWD 4D UTV 4-2.0L Gasoline Sequential MPI other VIN: JTNKHMBX4M1120656 Interior Color:
Mileage In: 7,633 Vehicle Out:
License: Exterior Color: other Mileage Out:
State: CA Production Date: Condition:
Job #:
TRANSMISSION INSTRUMENT PANEL SATELLITE RADIO
GLASS & MIRRORS
AUTOMATIC TRANSMISSION TRACTION CONTROL SAFETY DUAL MIRRORS
DRIVER CONVENIENCE STABILITY CONTROL DRIVERS SIDE AIR BAG
SIGNAL INTEGRATED MIRRORS
KEYLESS ENTRY LANE DEPARTURE WARNING PASSENGER AIR BAG
TINTED GLASS
POWER WINDOWS AIR CONDITIONING FRONT SIDE IMPACT AIR BAGS SEATS
POWER LOCKS CLIMATE CONTROL HEAD/CURTAIN AIR BAGS CLOTH SEATS
POWER MIRRORS REAR DEFOGGER REAR SIDE IMPACT AIR BAGS BUCKET SEATS
HEATED MIRRORS HANDS FREE DEVICE PAINT REAR END
CRUISE CONTROL COMMUNICATION SYSTEM CLEARCOAT PAINT BACKUP CAMERA
INTELLIGENT CRUISE RADIO FRONT END REAR WINDOW WIPER
INTERMITTENT WIPERS AM RADIO XENON OR L.E.D. HEADLAMPS REAR SPOILER
TILT WHEEL FM RADIO CALIFORNIA EMISSIONS WHEELS
TELESCOPIC WHEEL STEREO POWER STEERING 4-WHEEL DISC BRAKES
STEERING WHEEL TOUCH SEARCH/SEEK POWER BRAKES STYLED STEEL WHEELS
CONTROLS
CONSOLE/STORAGE AUXILIARY AUDIO CONNECTION ANTI-LOCK BRAKES (4) 12/9/2021 4:57:59 PM 309127 Page 1
Estimate of Record
RO Number: 8738
2021 TOYO C-HR LE FWD 4D UTV 4-2.OL Gasoline Sequential MPI other Line Oper Description Part Number
Qty Extended Labor Paint
1 Price$
WHEELS
2 * Repl LT/Rear Wheel, alloy 18", Japan
4261110371 1 534.42 m Incl.
built type B
Note: GOUGED
3 # Subl Mount & Balance
20.00 x
4 # Subl 4 Wheel alignment
79.95 X
5 R&I Spare Wheel, spare
6 REAR DOOR 0.2
7 * Rpr LT Outer panel
8 3.0 2.0
Add for Clear Coat
# 0.8
RFN ADJ
1 -0.3
10 * R&I LT Belt molding black Japan built
0.2 R&I LT Lower molding Japan built 0.3
12 QUARTER PANEL
13 Repl LT Wheel opng midg 7560610010
1 95.68 0.4
14 * Rpr LT Quarter panel Japan built
15 3.0 22
Overlap Major Adj. Panel -0.4
16 Add for Clear Coat
17 0.4
# RFN ADJ 1
18 -0.2
REAR LAMPS
19 R&I LT Tail lamp
0.4 REAR BUMPER
21 O/H rear bumper
22 2.8
R&I R&I bumper cover Inc.
23 Rpr Bumper cover Japan built
3.0 2.6
24 Add for Clear Coat
1.0 25 # RFN ADJ
1 -0.3
26 Repl Lower cover Japan built 5245310010 1 175.93
Incl.
Note: SCRAPED
27 R&I RT Trim panel Japan built Incl.
28 R&I LT Trim panel Japan built
Incl.
29 R&I Center bezel Japan built 0.1
30 VEHICLE DIAGNOSTICS
31 * Rpr Post-repair scan
m 0.3 M
32 TIRES
33 * Repl DNLP 225/50R18 DU03391
1 245.00 0.3
34 MISCELLANEOUS OPERATIONS
35 * Repl Cover car/bag 1
0.0 0.2
36 # Corrosion Protection 1 10.00 T 0.3
37 # Flex Additive 1 5.00 T
38 OTHER CHARGES
39 # E.P.C. 1 3.00
12/9/2021 4:57:59 PM 309127 Page 2
Estimate of Record
RO Number: 8738
2021 TOYO C-HR LE FWD 4D UTV 4-2.OL Gasoline Sequential MPI other SUBTOTALS 1,168.98 14.3
8.0 NOTES
Prior Damage Notes:
ESTIMATE TOTALS
Category Basis Rate
Parts Cost $
Body Labor 1,051.03
14.0 hrs @ $ 46.00 /hr 644.00
Paint Labor
8.0 hrs @ $46.00 /hr 368.00
Mechanical Labor
0.3 hrs @ $ 85.00 /hr 25.50
Paint Supplies 8.0 hrs
@ $ 34.00 /hr 272.00
Miscellaneous
Other Charges 114.95
3.00 Subtotal
2,478.48
Sales Tax
$ 1,338.03 8.7500% 117.08
Grand Total
2,595.56
Deductible
CUSTOMER PAY 250.00
250.00
INSURANCE PAY
2,345.56
This is not an authorization to repair.
All GEICO customers have the right to have their vehicle repaired in the shop of their choice.
No Supplement will be honored unless authorized by GEICO.
NOTICE: Vehicles constructed of special metals may require the use of specialized welding and bonding equipment.
Proper measuring and structural repair systems are required on today's vehicle to accurately accomplish vehicle repairs. Make sure your shop has the proper equipment to repair your vehicle.
ALTERNATE PARTS DISCLAIMER:
IF A QUALITY REPLACEMENT PART (A/M, LKQ, RECOND OR OPT OEM) APPEARS ON THIS ESTIMATE, IT INDICATES
THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. GUARANTEES, IF ANY, APPLICABLE TO
THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PART MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
***IN ADDITION TO ANY SUCH GUARANTEES, GEICO PROVIDES THE FOLLOWING:
****OWNER LIMITED GUARANTEE**** WE GUARANTEE THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS
NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS. THIS PARTS AND LABOR GUARANTEE WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE.
THIS GUARANTEE COVERS THE COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND 12/9/2021 4:57:59 PM 309127
Estimate of Record
RO Number: 8738
2021 TOYO C-HR LE FWD 4D UTV 4-2.0L Gasoline Sequential MPI other MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS GUARANTEE DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE.
LOCAL GEICO REPRESENTATIVE. IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR All repairs include a Lifetime Warranty against defects in materials & craftsmanship. Any parts used or replaced as part of the repair are subject to the warrany and/or guarantee of the manufacture of those parts.
The Lifetime Warranty in non-transferable and is limited to the Original Owner of the vehicle ONLY for as long as he/she own the vehicle.
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.
THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:
MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART, A=APPROXIMATE PRICE. LABOR TYPES: B=BODY LABOR, D=DIAGNOSTIC, E=ELECTRICAL, F=FRAME, G=GLASS, M=MECHANICAL, P=PAINT LABOR, S-STRUCTURAL, T=TAXED MISCELLANEOUS, X=NON TAXED MISCELLANEOUS. CCC ONE: ADJ=ADJACENT, ALGN=ALIGN, A/M=AFTERMARKET, BLND=BLEND, CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT, EST=ESTIMATE, EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED, MISC=MISCELLANEOUS, NAGS=NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ=NON ADJACENT, O/H=OVERHAUL, OP=OPERATION, NO=LINE NUMBER, QTY=QUANTITY, RECOND=RECONDITION, REFN=REFINISH, REPL=REPLACE, R&I=REMOVE AND INSTALL, R&R=REMOVE AND REPLACE, RPR=REPAIR, RT=RIGHT, SECT=SECTION, SUBL=SUBLET, LT=LEFT, W/O=WITHOUT, W/_=WITH/_ SYMBOLS: #=MANUAL LINE ENTRY, *=OTHER [IE...MOTORS DATABASE INFORMATION WAS CHANGED], **=DATABASE LINE WITH AFTERMARKET, N=NOTES ATTACHED TO LINE. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. "CURE TIME" MEANS THE LENGTH OF TIME THAT, PER THE ADHESIVE MANUFACTURER, THE WINDSHIELD
ADHESIVE NEEDS TO CURE UNTIL THE WINDSHIELD CAN PROPERLY FUNCTION AS A SAFETY DEVICE PURSUANT TO THE FEDERAL MOTOR VEHICLE SAFETY STANDARDS AND THE VEHICLE MANUFACTURER'S SPECIFICATIONS. 12/9/2021 4:57:59 PM 309127
Estimate of Record
RO Number: 8738
2021 TOYO C-HR LE FWD 4D UTV 4-2.0L Gasoline Sequential MPI other Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are manufactured by or for the otherwise noted, (a) all items are derived from the Guide ARM8565, CCC Data Date 12/01/2021, and potentially other vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts are available at OE/Vehicle dealerships or the specified supplier. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships with discounted pricing. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor data provided by third party sources of data may have been modified or may have come from an alternate data source.
Tilde sign (~) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non OEM, A/M or NAGS. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2022 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Incl.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF International Certified Part. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Intelligent Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 12/9/2021 4:57:59 PM 309127
Estimate of Record
RO Number: 8738
2021 TOYO C-HR LE FWD 4D UTV 4-2.OL Gasoline Sequential MPI other
WE WARRANT THAT ALL PARTS USED IN THE REPAIR OF THIS VEHICLE ARE EQUAL TO THE ORIGINAL EQUIPMENT WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT AND PERFORMANCE. THIS PARTS AND LABOR
WARRANTY COVERS THE COST ASSOCIATED WITH RETURNING THE PART AND THE COST TO REMOVE AND
REPLACE THE NON-ORIGINAL EQUIPMENT MANUFACTURER PART WITH A COMPLIANT NON-ORIGINAL EQUIPMENT PART OR AN ORIGINAL EQUIPMENT MANUFACTURER PART. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS WARRANTY IS NOT TRANSFERABLE. IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, YOU MUST CONTACT YOUR LOCAL GEICO REPRESENTATIVE.
If a customer subsequently chooses a repair shop, GEICO shall prepare a supplement using the prevailing rate in the Geographic Area of the customer's chosen shop.
This is not an authorization to repair. The undersigned repair facility is in agreement to the estimate prepared by GEICO in the amount of $ _. No supplements will be honored by GEICO without prior approval.
Signed:
Print Name:
Date:
We are required under sect 2695.7(b) of the Unfair Claims Settlement Practices Regulations to provide the following notice: If you believe that your claim has been wrongfully denied or rejected, you also have the right to have the California Department of Insurance review this matter. The Department of Insurance is located at 300 South Spring Street, Los Angeles, CA 90013, telephone number (800) 927-4357. 12/9/2021 4:57:59 PM 309127
Estimate of Record
RO Number: 8738
2021 TOYO C-HR LE FWD 4D UTV 4-2.OL Gasoline Sequential MPI other
TIRE PARTS SUPPLIERS
Line Description Supplier
33 DNLP 225/5018 Price
Big O
$ 245.00
2625 SAN PABLO AVE, BERKELEY CA 94702-0 (510) 843-9633
12/9/2021 4:57:59 PM 309127
Estimate of Record
RO Number: 8738
2021 TOYO C-HR LE FWD 4D UTV 4-2.0L Gasoline Sequential MPI other
ALTERNATE PARTS USAGE
2021 TOYO C-HR LE FWD 4D UTV 4-2.0L Gasoline Sequential MPI other VIN: JTNKHMBX4M1120656 Interior Color:
Mileage In: 7,633 Vehicle Out:
License: Exterior Color:
other Mileage Out:
State: CA Production Date:
Condition: Job #:
Alternate Part Type Selection Method # Of Times Notified Of # Of Parts Selected
Available Parts
Aftermarket Manually List
0 Optional OEM Manually List 0
0 Reconditioned Manually List 0
0 Recycled N/A 0
0 12/9/2021 4:57:59 PM 309127
ARMS CECO Rental Company: Enterprise Rent-A-Car
Invoice: 32G2D542W7R
Alternate Invoice
Number: 542W7R
Bill To: GEI3284 RENTAL DETAIL:
GEICO
ATTN:DESTINY CE84-COURTNEY Rental Period: 12/07/2021 to 01/03/2022 (28 days) PO BOX 509090 Billed Period: 12/07/2021 to 01/03/2022 (28 days) Description Quantity Rate Amount
SAN DIEGO, CA 921509090 TIME & DISTANCE
RENTER INFORMATION: 28 $25.00 $700.00
VEHICLE LICENSE
Renter: PLASCENCIA, ANTONIO RECOVERY FEE 28 $1.37 $38.36 Address: SALES TAX 1 7.75%
$54.25
RIALTO, CA 923760000 Total Charges: $792.61
Home Phone: Less Amount Received:
$0.00
Office Phone: Total Amount Due:
$792.61
RENTAL INFORMATION:
Rental Branch Location:
ENTERPRISE RENT-A-CAR(32G2)
8868 SIERRA AVENUE
FONTANA, CA 923358649
ADDITIONAL CLAIM INFORMATION:
Claim Number: 054620188010102401
Claim Type: Insured
Vehicle Condition: Non-Driveable
Date Of Loss: 12/05/2021
Insured Name: PLASCENCIA,ANTONIO
Owner's Vehicle: 2021 TOYOC-HR
Assign type: Xpress Field
ClaimNumber: 0546201880101024
IPNumber: 01
Internet Self Serve: No
Days To Repair: 12
RenterName: ANTONIOPLASCENCIA
NumberofDaysAuthorized: 0
Invoice Target: ATLAS
Source: PD_CLOUD
Shop Code: XQB
Automated Extension:
Line of Business: APV
Class Segment:
CatActive: False
Catindicator: False
CatCode: NULL
Repair Facility:
COLLISION CENTER OF SAN BERNARD
SAN BERNARDINO, CA 92410
(909) 453-0933
VEHICLES RENTED:
Effective Date /Time | Mileage
12/07/2021 14:59 PM 2021 KND23AU4M7752203 393
Rental Invoice
Please Return This Portion with Remittance
Make Payment To: Total Charges:
ENTERPRISE RENT-A-CAR $792.61
Less Amount Recelved:
P.O. BOX 840086 $0.00
Total Amount e…...…. $792.61
KANSAS CITY, MO 641840086 Please Include on your Check:
Federal ID: 43-0724835
Invoice:32G2D542W7R
Account No: 31405
GEICO-CA EM
ATTENTION: 03awzg
12/14/2021
PLEASE REPLY TO:
Metropolitan Reporting Bureau
BOX 926, William Penn Annex
Philadelphia, PA 19105-0926
800) 245-6686 or [email protected]
FAX (800) 343-9047
NOTICE
INSURED
: ANTONIO PLASCENCIA
CLAIM NUMBER : 0546201880101024
POLICY NUMBER
DATE OF LOSS : 12/05/21
STATE OF LOSS
REPORT REQUESTED: AUTO ACCIDENT
THANK YOU,
MRB
CONTROL NUMBER
3331103866
Claim Number 0546201880101024
Pay To The Order Of M B Collision
Financials
Gross Amount $2,345.56
Net Amount
$2,345.56
Backup Withholding $0.00
Payment Identification
Issued Date 12/10/2021
Mail To Name M B Collision
Mail To Address
Memo
Payment Type Electronic funds transfer
Check Number
Related Documents
Document Name
Reserve Line Allocation
Exposure Reserve Line:
Cost Type Amount
Antonio Suarez Plascencia - Collision (2021 Collision
TOYOTA) Loss $2 345.56
Claim Number 0546201880101024
Pay To The Order Of Quality Roadside Service
Financials
Gross Amount $45.00
Net Amount
$45.00
Backup Withholding $0.00
Payment Identification
Issued Date 12/23/2021
Mail To Name Quality Roadside Service
Mail To Address
Memo
ERS - Collision
PO# G1106021341
Payment Type Electronic funds transfer
Check Number
Related Documents
Document Name
Reserve Line Allocation
Exposure Reserve Line:
Cost Type Amount
Antonio Suarez Plascencia - Collision (2021 Collision
TOYOTA) Loss $45.00
Claim Number
0546201880101024
Pay To The Order Of Quality Roadside Service
Financials
Gross Amount $65,00
Net Amount $65.00
Backup Withholding $0.00
Payment Identification
Issued Date 12/09/2021
Mail To Name Quality Roadside Service
Mail To Address
Memo ERS - Collision
PO# G1106021341
Payment Type Electronic funds transfer
Check Number
Related Documents
Document Name
Reserve Line Allocation
Exposure Reserve Line
Cost Type Amount
Antonio Suarez Plascencia - Collision (2021 Collision Loss TOYOTA) $65.00
Claim Number 0546201880101024
Pay To The Order Of ENTERPRISE RENT A CAR/ATTN
ACCOUNTS RECEIVABLE
Financials
Gross Amount $792.61
Net Amount $792.61
Backup Withholding $0.00
Payment Identification
Issued Date 01/13/2022
Mail To Name ENTERPRISE RENT A CARIATTN ACCOUNTS
RECEIVABLE
Mail To Address
Memo
Rental Reimbursement
32G2D542W7R
Payment Type Electronic funds transfer
Check Number
Related Documents
Document Name
Reserve Line Allocation
Exposure Reserve Line
Cost Type Amount
Antonio Suarez Plascencia - Rental (2021 Rental Reimbursement TOYOTA) Loss S792.61
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17009748
28150 N Alma School Parkway #103-642 RETAIL FROM 95008
Scottsdale, AZ 85262
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RETURN SERVICE REQUESTED
05/11/2022
USPS FIRST CLASS MAIL®
Subro Claims, Inc
28150 N Alm School Pkwy Ste 103-642
Scottsdale AZ 85262-8061
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TO: City of Rialto
Attn Office of the City Clerk
150 S Palm Ave
Rialto CA 92376-6406
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