CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
2022 SEP - 7
TO PERSON OR PROPERTY
PM 1: 44
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
Rialto City Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Jason Sanders
FULL NAME DATE OF BIRTH
Riatto 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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: June 22,2022 T TIME: 3:18 DAM EPM
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.
IT W Aback St There were 2 Tres in the jack and way day On June 22. The wind was blaving on the tree
back of my Nissan maxima at 3.18 2000 Nissan Maxima gold
3. HOW DID DAMAGE OR INJURY OCCUR?
A tree in the yard fell on the back of my car.
4. WERE POLICE AT THE SCENE? •YES NO WERE PARAMEDICS AT THE SCENE? • YES ENO
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.
N
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $5,205.93 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: 08-11-22 Caliber Callison (909) 874-4470 Amount: $5205.98 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 5;205,93 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 8-11-22 Calibercollisicn (009) 874-447 Amount: $ 5:205.93 Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 5,205.93
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: _ Toi long NAME:
ADDRESS: ADDRESS:
92377
TELEPHONE: TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: | 2 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.
Areth
PARKWAY
SIDEWALK
Tree
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 PER.JURY THAT THE FOREGOING IS TRUE AND CORRECT. ason Sanders
.-
SIGNATURE OF CI AIMANT OR AGENT O 9-07-22
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 CALIBER - RIALTO Workfile ID: 831fa325
CALIBER Federal ID: 33-0730794
RESTORING THE RHYTHM OF YOUR LIFE State ID: N/A
421 West Rialto Avenue, RIALTO, CA 92376 Federal EPA: N/A State EPA: CAL000265317
COLLISION Phone: (909) 874-4470 BAR:
ARD299767
FAX: (909) 874-4561
Preliminary Estimate
Customer: Sanders, Jason
Written By: Jason S Jimenez
Insured: Sanders, Jason Policy #: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 16 Non-Collision
Owner: Inspection Location: Insurance Company:
Sanders, Jason CALIBER - RIALTO CUSTOMER PAY
421 West Rialto Avenue
RIALTO, CA 92376
Repair Facility
(909) 874-4470 Business
VEHICLE
2000 NISS Maxima SE Automatic 4D SED 6-3.0L Gasoline SMPI GOLD VIN: Interior Color: TAN Mileage In: 240,953 Vehicle Out:
License: Exterior Color: GOLD Mileage Out:
State: Production Date: 12/1999 Condition: Job #:
TRANSMISSION Console/Storage FM Radio Bucket Seats
Automatic Transmission CONVENIENCE Stereo Reclining/Lounge Seats POWER Air Conditioning Search/Seek WHEELS
Power Steering Intermittent Wipers CD Player Aluminum/Alloy Wheels Power Windows Tilt Wheel Cassette PAINT
Power Locks Cruise Control SAFETY Clear Coat Paint
Power Mirrors Rear Defogger Drivers Side Air Bag Metallic Paint DECOR Keyless Entry Passenger Air Bag OTHER
Dual Mirrors Alarm 4 Wheel Disc Brakes Fog Lamps
Body Side Moldings RADIO SEATS Rear Spoiler
Tinted Glass AM Radio Cloth Seats Power Trunk/Liftgate
8/11/2022 10:11:05 AM 036535 Page 1
Preliminary Estimate
Customer: Sanders, Jason
2000 NISS Maxima SE Automatic 4D SED 6-3.0L Gasoline SMPI GOLD 40 Repl RT Bumper cover clip 85284AD000 4 30.04 Incl.
41 Repl LT Bumper cover clip 85284AD000 4 30.04 Incl.
42 VEHICLE DIAGNOSTICS
43 # Pre-repair scan 1 40.00 X 0.5
44 # Post-repair scan 1 80.00 x 0.5
45 # Cover Car for Overspray 1 12.00 X 0.3
46 # Repl Corrosion Protection / Primer 1 15.00 T 0.3
47 Rpr D&R Battery 0.5
48 Flex Additive 1 12.00 T
49 # DeNib and Polish 1 18.00 X 1.0
50 # Refn Color Tint 0.5
51 # Rope Back Glass 1 6.00 x 0.5
52 OTHER CHARGES
53 # E.P.C. 1 20.00
SUBTOTALS 2,053.77 20.6 12.0
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 1,850.77
Body Labor 20.6 hrs @ $ 72.00 /hr 1,483.20
Paint Labor 12.0 hrs @ $72.00/hr 864.00
Paint Supplies 12.0 hrs @ $ 51.00 /hr 612.00
Miscellaneous 183.00
Other Charges 20.00
Subtotal 5,012.97
Sales Tax $2,489.77 @ 7.7500 % 192.96
Grand Total 5,205.93
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MAXIMA