CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
2022 JUN -3 PM 3: 52
CLAIM FOR DAMAGES
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:
oSa sther Murdoch
FULL NAME DATE OF BIRTH
Colton CA
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: _ 05/21/2022 TME: 3:30 2 AM EI 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. i Linden Ave• Kialto 92374. CA.
1 ша оп ту наді ша u Linden
then I Turned into the muddle lane as / cuas approaci
160 Nomen Ave Rial, CA 92370) Juarging to tom left then I heard a loud nose se on the sedi was felters 770 ceave that oft. I called the sec rity and he same book to check with me on the street see, what wa cron
WERÉ PARAMÉDICS AT THE'SCENE? main covered. atlache
5. WHAT PARTICULAR ACTOR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name offthe city/town photo a il. 4 employee causing the injury or damage, if known.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ 1412.14 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: _ 05/20/2022 14/2.14
Amount: $
Item/Date: Amount: $
2 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
- Item/Date: - 05 2 4 2022 14/2,14
Amount: $.
Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 1412.14
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: A -
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: ( ) TELEPHONE: L)
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 comers.
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. inden
L6B7
7 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 CERTIFY (OR DECI ARF) INNER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
osa Ls than Hordich 06/03/2022.
TYPE OR PRINT NAME DATE
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150S. PALM AVE., RIALTO, CA 92376 3 PROCOLOR - RIALTO Workfile ID:
cee4657c
1561 S. LILAC AVE, BLOOMINGTON, CA 92316 PartsShare: 6MWST4 Phone: (909) 990-5019 State EPA: CAL000436081
FAX: (909) 990-5024 BAR: ARD00291403
Estimate
RO Number:
Customer: Insurance:
Adjuster: Estimator:
Murdoch Yeah models yes, Roza Eddy Samawi
Phone: Create Date:
5/24/2022
Claim:
Loss Date:
909) 264-5066
Deductible:
2019 TOYO Corolla LE w/Continuously Variable Transmission 4D SED 4-1.8L Gasoline Sequential MPI white VIN:
Interior Color: black
License: Mileage In: 47,322 Vehicle Out:
Exterior Color: white
State: Mileage Out:
Production Date: 1/2019
Condition: Job#:
Line Ver Operation
Description Qty Extended Part
Labor Type Paint
1 Price $ Type
E01
FRONT BUMPER
E01 Remove/Replace O/H front bumper
3 E01 Remove/Replace 2.1 Body
Bumper cover 1
265.92T OEM
4 E01 0.0 Body 2.6
Add for Clear Coat
5 E01 Remove/Replace 1.0
RT Hole cover w/o bumper DRL 1 52.44T OEM
6 E01 0.0 Body
FENDER
7 E01 Remove/Replace
RT Fender liner 1
8 99.10T OEM 0.4 Body
E01 Remove/Replace
RT Fender liner retainer 1 4.88T OEM
9 E01
VEHICLE DIAGNOSTICS
10 E01 Repair Pre-repair scan
11 E01 Repair 0.5 Mech
Post-repair scan
12 E01 Sublet 0.5 Mech
Hazardous waste removal 1 5.00T
Other
13 E01 Repair Color tint / color match
14 E01 Repair Color sand and buff 0.5 Body
0.5 Body
Estimate Totals Discount $
Markup $ Rate $ Total Hours
Parts Total $
105.59
Sublet/Miscellaneous 527.93
Labor, Body 5.00
72.00 3.5
Labor, Refinish 252.00
72.00 3.6
Labor, Mechanical 259.20
125.00 1.0 125.00
Material, Paint
52.00 3.6 187.20
Subtotal
1,356.33
Sales Tax
Grand Total 55.81
1,412.14
Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech = T = Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman = Mechanical, Ref = Refinish, Struc = Structural
5/24/2022 9:56:11 AM
Estimate
RO Number:
2019 TOYO Corolla LE w/Continuously Variable Transmission 4D SED 4-1.8L Gasoline Sequential MPI white Net Total
1,412.14
Estimate Version
Total $
Original
1,412.14
Insurance Total $:
0.00 Received from Insurance $:
0.00 Balance due from Insurance $:
0.00 Customer Total $:
1,412.14
Received from Customer $:
0.00 Balance due from Customer $:
1,412.14
(U) Used, is used parts, (LKQ) Like, Kind & Quality, is used parts. (G) Is Glass. (O) Is other parts as described. Operations: R&R= Remove and Replace. Parts Definitions: (D) Domestic or (F) Foreign are new and made by the original equipment manufacturer (OEM). (A) is Aftermarket, new, non-OEM.
Repl= Replace. R&I= Remove and Install. Repr= Repair. O/H= Overhaul.
Estimate of repairs include all visibly damaged parts, labor, handling and diagnosis. If on closer inspection or during disassembly, it is found that additional repairs are required, you will be contacted for additional authorization to proceed. If the vehicle is returned to the customer before authorized repairs are performed, a diagnostic, handling charge and a $125 Administration fee, not excluding reassembly and/or storage charges of $80 a day will be assessed.
DELIVERY DATE:
Because of the possibility of unseen damage and the uncertainty of part availability, delivery dates are NOT guaranteed. When the damaged areas are disassembled and parts availability has been researched, we (your estimator) will contact you with a more specific target date.
TEARDOWN/DISASSEMBLY AUTHORIZATION:
I hereby authorize ProColor Collision to teardown and or disassemble my vehicle for the purpose of providing a proper estimate and do hereby acknowledge my financial obligation to pay for the service rendered unless paid for by my insurance carrier. Unless otherwise noted, the vehicle will not be reassembled and that teardown/disassembly may render the vehicle non-drivable. Days to reassemble (if applicable) Teardown Fee: $350 Signature: Date:
AUTHORIZATION TO REPAIR:
If applicable, I authorize ProColor Collision to act as my agent in negotiating the final cost of repairs with my insurance company. I hereby authorize the work described herein, to be performed, including, but not limited to all sublet work and grant you and your employees permission to operate the vehicle on the streets and highways for the purpose of repairing and/or testing the vehicle and acknowledge receipt of this estimate. I understand that I am responsible for the payment of the repair costs and agree in the event of legal action that I will be held financially responsible for any and all fees relating to the action including, but not limited to all court, filing and attorney fees. I acknowledge at no time does Pro Color Collision accept Personal Signature: Date:
NEW NON-OEM AFTERMARKET PARTS AUTHORIZATION:
I elect and approve the use of new, non- original manufacturer replacement parts and/or used recycled parts during the repair of my vehicle. I acknowledge that I have been informed of my options regarding the different types of replacement parts that are available for my vehicle as part of the repair process.
Signature: Date:
VERBAL AUTHORIZATION TO REPAIR:
Verbal authorization for the amount of $
T= Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman = Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech = Mechanical, Ref = Refinish, Struc = Structural
5/24/2022 9:56:11 AM
5 Estimate
RO Number:
2019 TOYO Corolla LE w/Continuously Variable Transmission 4D SED 4-1.8L Gasoline Sequential MPI white Authorized by:_
Phone #: Date:
DESIGNATION OF PERSON(S) TO AUTHORIZE ADDITIONAL WORK/PARTS:
I hereby designate the individual named below to authorize any additional work and/or parts not originally specified in the Original Estimate, inclusive of parts, labor and/or sublet repairs.
Name:
Phone #:
Signature:
Date:
SUPPLEMENT # 1- VERBAL AUTHORIZATION:
Verbal additional amount authorized: $
Description: Estimate
Authorized by:
Phone #:
Date: Time:
am/pm.
Revised Estimate amount:$.
MISSING ARTICLES OR THEFT:
I understand that ProColor Collision will NOT be held responsible for theft of vehicle or missing articles left in vehicles such as: Wallet/Purse, Cell Phones, IPods, Cameras, Sunglasses, Credit Cards, Money, Cd's, Golf Clubs, etc. PLEASE REMOVE ALL PERSONAL ITEMS FROM YOUR VEHICLE BEFORE OR WHEN YOU DROP OFF YOUR VEHICLE FOR REPAIRS.
Signature: Date:
ACKNOWLEDGEMENT OF NOTICE AND CONSENT:
I acknowledge notice and oral approval of an increase in the original estimate amount as described/explained. I authorize the Insurance company to pay ProColor Collision direct for all supplemental and original repairs. vehicle until all such repair costs have been paid. I further agree to pay reasonable attorney's fees and court costs in the event that legal action is To secure payment for repairs authorized above, I (we) acknowledge that this repair facility has alien on my vehicle and may retain possession of my necessary to enforce this contract.
Signature.- Date:
If the repair is an insurance claim, the undersigned hereby grants ProColor Collision Power of Attorney to sign my name as an endorsement on any insurance check and/or draft. **IF THE INSURANCE CHECK IS CASHED BY THE CUSTOMER HE/SHE UNDERSTANDS THAT UPON PICK UP OF THE VEHICLE THE TOTAL AMOUNT OF THE INSURANCE CHECK IS DUE IN CASH ONLY.** Signature:
Date:_
Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech = T = Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman = Mechanical, Ref = Refinish, Struc = Structural
5/24/2022 9:56:11 AM
Details Details
May 21, 2022 3:33 PM May 21, 2022 3:33 PM
20220521_153326.jpg 20220521_153325.jpg
/Internal storage/DCIM/Camera
/Internal sto age/DCIM/Camera
7,08 MB 4032x3024
7.04 MB 4032x3024
Auto tag
Auto tag
Buckets Tools
Nuts Scenery Streets Tools
Samsung SM-N960U
Samsung SM-N960U
F2.4 1/1726 s 4.30mm SO 50
Date: 06/03/2022
Name:
Phone:
Address:
Rialto, CA 92376
On Saturday, May 21, 2022 at Approximately 1530 hours Rosa Mudoch Approached me at the guard shack of Amazon LGB7 Entrance and informed me that there was a hole in the middle of Linden Ave and that it had caused damaged to her car, I was able to go out to the street and take a picture of what appear to be an open water access line.
Saul Martinez
Printed name Signature
8