CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2022 JUN 16 PM 12:28
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).
RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING
Rialto City Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
ROBERT BOCANEGRA
-
FULL NAME DATE OF BIRTH
RIALTO, CA 92377
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 WAWANESA INS. PO BOX 82867
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): SAN DIEGO CA 92138
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 03-23-2022 TIME: 605 • AM • 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.
FRISBEE PARK FRONT ENTRAGE GATE RIALTO CA
3. HOW DID DAMAGE OR INJURY OCCUR?
THE PARK ENTRANCE GATE WAS NOT SECURED IT SWUNG OPEN AND STRUCK THE 2013 CHEVY CRUZE
4. WERE POLICE AT THE SCENE? OWES •NO WERE PARAMEDICS AT THE SCENE? • YES ANO
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 GATE WAS NOT SECURED AND LOCKED ALLOWING THE GATE TO FREELY SWING OPEN STRIKING WHATEVER WAS IN ITS PATH.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $8702.76 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: TOTAL LOSS VEHICLE Amount: $8702.76
Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $8202.76 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: INSURED DEDUCTIBLE Amount: $500
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $8702.76
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: SEE PR NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: _)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L 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.
CATE AT THEATROTE OF THE PLOT
CURB
PARKWAY
SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUI I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Dustin Cernitz, adjuster For Wawanesa insurance as Subrogee ROBERT BOCANEGRA.
SIGNATURE OF CLAIMANT OR/AGEN
DUSTIN CERNITZ 05-12-2022
TYPE OR PRINT NAME DATE
INSURANCE COMPANY
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
CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 2022 JUN 16 PM 12:28
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 §911.2). CITY CLERK
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:
FULL NAME DATE OF BIRTH 7
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. t0 92322
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: 3/23/2022 _ TIME: 60605 DAMDPM
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. + Shee HaRk FRont EntRance Gale in Kialto
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3. HOW DID DAMAGE OR INJURY OCCUR?
EntRance Gate Was no secuReD
Cend Swung Oper and SRuck ня 701
Chevy cruz
4. WERE POLICE AT THE SCENE? • 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.
Las
Create se lacket
жене Оден
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 500.02 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
eductable Amount: $ 500,02
Item/Date:
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $500.01) ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: use detectable Amount: $ 500,0z
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: LAM 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.
В ракк
CURB
PARKWAY
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 DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
KobeRt D. Bicanegra S/18/7227
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 - 150 S.PALM AVE., RIALTO, CA 92376 Wawanesa WAWANESA GENERAL INSURANCE COMPANY
PO Box 82867 San Diego, CA 92138-9492
Insurance Claims Department Toll Free: 1-888-WAWA-CLAIM Policy Service 858-874-5300 or Toll Free 1-800-640-2920 June 10, 2022
RIALTO CITY CLERKS OFFICE
150 S Palm Ave City of Rialto
Rialto California 92376-6487
RE: Date of Loss: March 23, 2022
Our Insured: Robert Bocanegra
Claim Number: 000000001885854
Dear Rialto City Clerks Office,
Requested action:
- For your information. CITY CLERK RECEIVED 2022 JUN 16 PM 12:28 CITY OF RIALTO Thank you for your courtesy and cooperation.
Sincerely,
Dustin Cernitz
Inside Claims Representative lI
Phone: 888-929-2252 x1506611
Fax: 619-584-1009
Email: [email protected]
For information about the types of personal information we collect and how we use it, visit our Privacy Policy at www.wawanesa.com.
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Insurance 06/10/2022
US POSTAGE $008.5€
7650 Mission Valley Rd. 7022 0410 0001 9503 7731 ZIP 92108 San Diego, CA 92108-4423 041M114583
CITY OF RIALTO 2022 JUN 16 PM12:28 RECEiVEr CIT Y CLERR