CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2022 NOV 18 PM 3:26
TO PERSON OR PROPERTY
RECEIYED
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 59112) TY CLERK
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:
FRANCISCO Albert SpagNA DATE OF BIRTH
FULL NAME
HOME ADDRESS INCLUDING CITY, STATE & ZIP dictorville Ca 92395 HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Francisco Albert Spagna NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM victorville (if different from home address provided above):
92395
1. WHEN DID DAMAGE OR INJURY OCCUR DATE 0C$ 12,2022 TIME: 7:45 0AMBPM
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.
3. HOW DID DAMAGE OR INJURY OCCUR?
from 330 resoure Dr, Riverside + big ditchte 15 N
sierra daily for Il months, I hit open big ditch or
high level bumpy street non flat street.
4. WERE POLICE AT THE SCENE? DYES ENO WERE PARAMEDICS AT THE SCENE? O 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.
Rialto Ca, from Bloomingto on - Riverside to sierra Ave 15 N freeway north and south within. 9 miles All the
streets are damagged
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2,023.39 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: Oct 18, 2022 Amount: $1,10000
Hem/Date: NOV 11, 2022 Amount: $_ 2,023.39
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: oct 18,2022 Amount: $_ 1, 100 %°
Item/Date: Nov Il, 2022 Amount: $ 2,023.39
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 2,023.39
1. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) ser
NAME: OSCAr - number 367825) NAME: Tony Owner.
ADDRESS: CaLifornia Towing ADDRESS: —
fontana la Hesperia Ca. 92345
TELEPHONE: TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME: _
ADDRESS: _ ADDRESS:
TELEPHONE: TELEPHONE: )
DATE: TIME: DATE: _ TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehice 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
7/1 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 THOSÉ 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
FRANCISCO Albert SPAGNA 11•12•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 - 150 S. PALM AVE., RIALTO, CA 92376 5 Noith freeway
y+ros
aA FASIS
Sierra Ave
North
south Riverside Spistany yt1on
+sam
<s2r
zu zs09 auasig
South Riverside pastany ytione
11:4+00t 1'yfoet
south Riverside Ppissany YAION
JAlley VAlley
Riverside
2 south → ap! siany
resay
I barely clocked out my Tab
Location Fed ex 330 Resouice Dr.
Bloanington, I drive everyday on RiversideAve blooming ten Ca and After to 330 resource
to riverside And Sierra Ave were I
been catching to 15 N Freeway Home
to 14069 Drift wood Dr. Victorville Ca
92395. 9 miles from Riverside And valley
are destroyed, damadge Roads, ditches
holes Lumpy koads to sierra Ave 15
past Merril before foothill was Driving on Riverside
Riverside dark about 7:25 PM
and a Loud leff noise from my Car
I wasat sue what tine and Ruersid
no flat tire until I merge on the
freeway N15 and s
brakes to merge on Lane 2 and No Brakes.
I was Driving with no Brakes oN
a 45 miles ahour for 1/2 mile,
on the right lane theres an emergency
Lane were I was fortunetlly to have
my car slow down and click my
Parked lever to stop. I called ARA
they dıspatch someone in Rancho California Towing in fontana were Cuca monga. AAA Driver name oscar
service number#367825 saw leakage
and damadge were he towed the
car to Daves Auto repair
15940 Walnut st Hesperia Ca, 12345
KEMPER Policy underwritten by
Infinity Insurance Company
Named insured: Francisco Spagna
Kemper
P.O. Box 2843 Claimant: Francisco Spagna
Clinton, IA 52733
Claim number: 22123990538
Date of loss: October 18,
Francisco Spagna 2022
Date of mailing: November 11,
2022
Dear Francisco Spagna:
We are writing to you regarding the 2000 PLYM Voyager 113 Check of $2,023.39 will be issued once edocs and title received. DocAssist was emailed separately, your access code is
Please sign and mail the title to:
Insurance Auto Auctions
Title Center (West)
11017 Cobblerock Drive Suite 150
Rancho Cordova, CA 95670
Please sign name as it is written on title. Example of how to sign title is on next page.
If you have any questions, please contact us and have the claim number available so we can assist you as quickly as possible.
Sincerely,
William
Policy underwritten by
KEMPER
Infinity Insurance Company
Named insured: Francisco Spagna
Kemper
P.O. Box 2843 Claim number: 22123990538
Clinton, IA 52733
Date of loss: October 18, 2022
Date of mailing: October 20, 2022
AB 01 001982 14183 H 7 A
Francisco Spagna
Dear Francisco Spagna:
We completed our liability investigation of the above-referenced claim.
When traffic accidents result in damage to property, and the total loss or damage caused by the accident exceeds $1,000, an investigation must be undertaken to determine what actions or omissions from the drivers caused the accident.
California state regulations require us to notify you that we have determined that the driver of your vehicle was principally at-fault for this accident. The basis for this determination is that.
If you would like us to reconsider our determination that the driver was principally at-fault, you must notify us within 30 days after the receipt of this letter. We will then provide you with a written reconsideration decision within 30 days of our receipt of your request.
Our goal is to provide you with exceptional claims service. If you have any questions about the claims process, please contact me using the information below and reference the claim number at the top of this letter. You can also contact Kemper's claims customer service department at 800-3-KEMPER (800-353-6737). Our representatives are available Monday through Friday from 7:00 a.m. - 7:00 p.m., Central time.
Thank you for choosing Kemper.
KEMPER Policy underwritten by
Infinity Insurance Company
Named insured: Francisco Spagna
Kemper
P.O. Box 2843
Claimant: Francisco Spagna
Clinton, IA 52733
Claim number: 22123990538 000055 1/11
Date of loss: October 18, 2022
SP 03 000055 44951 G 4 ASNGLP
Date of mailing: November 11, 2022
Francisco Spagna
Miller |/alphyl
Dear Francisco Spagna:
We are writing to you to explain how the total loss and the salvage sale are processed for your above-referenced automobile material damage total loss claim. It is important you understand the process in order to resolve your claim in a timely manner, so please read this letter in its entirety.
The value of your vehicle was determined based on similar vehicles for sale in your local market, considering its pre-accident condition, accessories, options, and mileage. Please review the following offer:
Actual Cash Value (ACV) = $2,233.00
Total Sales Tax (8.75%) = 195.39
Registration Fees = 95.00
Deductible = (500.00)
Settlement Calculation = $2,023.39
Please contact your agent or broker to discuss removing this vehicle from your policy. Your agent or broker is the best resource for policy issues and can answer questions about how this claim may affect your policy.
You may be entitled to a premium credit. However, no changes will be made to your policy, as a result of this total loss, unless we receive instructions from you. In order to avoid paying unnecessary premium, please contact your agent or broker immediately to provide them with the information required to make the changes to your policy.
If you notify us within thirty-five (35) calendar days after you receive the claim payment that you cannot purchase a comparable automobile for the gross settlement amount, we will reopen the claim file.
Our goal is to provide you with exceptional claims service. If you have any questions about the claims process, please contact me using the information below and reference the claim number at the top of this letter. You can also contact Kemper's claims customer service department at 800-3-KEMPER (800-353-6737). Our representatives are available Monday through Friday from 7:00 a.m. - 7:00 p.m., Central time.
Sincerely,
Lucero Hernandez
Claims Team
T 800-353-6737, ext.2137002
F 888-976-2123
[email protected]
California - For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Claim #: 2212399053801
Workfile ID: 961513dd
Estimate of Record
2000 PLYM Voyager 113" WB 3D VAN 4-2.4L Gasoline SMPI White Line Орег Description Part Number Qty Extended Labor Paint Price $
Repl A/M Proportioning Valve 905-930 1 44.49 1.0 M
NOTE:
https://www.carparts.com/details/Chrysler/Grand_Voyager/Dorman/Brake_Proportioning_ Valve/2000/905930.h tm|?TID=ggipla&origin=&utm_source=google&utm_medium=pla&utm_cam paign=12190938700&gc|id=EAla|Qob ChMI_8XK8a6B-w|VXgutBh1znwK2EAQYByABEgLJxPD_BwE&gclsrc=aw.ds.
No longer available per Chyrsler
Repl A/M Brake Lines 0447240 1 344.00 8.0 M
NOTE: Fastenal.com pack of 10 lines.
Brake lines replacement all steel lines, lines run from front to back full length of vehicle, lines also run into unibody and over fuel tank. Will need bending and fittings.
Spoke to Tony from Dave's Automotive 760-244-0212 for liability reason he will not be repairing vehicle but dia inform me of the labor times he would start with for repairs 3 ** Repl A/M Brake fittings 1 20.00
# Rpr Bending of Fuel Lines 2.0 M
FRONT SUSPENSI ON
Repl Bleed brake system m 0.5 M
7 ** Repl A/M Brake Fluid 10.99 T
FUEL SYSTEM
R&I R&l fuel tank 5011939AA m 1.3 M
10 # Rpr Drain and Store Fuel 1.0 M
SUBTOTALS 419.48 13.8 0.0
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 408.49
Mechanical Labor 13.8 hrs @ $ 150.00 /hr 2,070.00
Miscellaneous 10.99
Subtotal 2,489.48
Sales Tax $ 419.48 8.7500 % 36.70
Total Cost of Repairs 2,526.18
Deductible 500.00
Total Adjustments 500.00
Net Cost of Repairs 2,026.18
447084 | 1.8.07.10200 Page 2
10/27/20224:58:13 PM
INFINITY INSURANCE COMPANY
William Stahl
FOR SUPPLEMENTS PLEASE CONTACT APPRAISER VIA PHONE OR EMAIL.
Kemper Repair Network shops: Est share 000055 2/11
PO BOX 2843
Clinton, IA 52733 Claim #: 2212399053801
Phone: (760) 488-7363 Workfile ID: 961513dd
Estimate of Record
Written By: WILLIAM STAHL, License Number: 447084, 10/27/20224:58:13 PM Adjuster: Mireles, Monserrath, (800) 353-6737 x1512364 Business Owner Policy#: Claim #: 2212399053801
Insured: Francisco Spagna
Date of Loss: 10/18/202207:30 PM Days to Repair:
Type of Loss: Comprehensive
Point of Impact: 15 Total Loss Deductible: 500.00
Inspection Location: Appraiser Information: Repair Facility:
Owner (Insured):
[email protected]
Francisco Spagna
Hesperia, CA 92345 (760) 488-7363
Field
Jay
VEHICLE
2000 PLYM Voyager 113* WB 3D VAN 4-2.4L Gasoline SMPI White Production Date: 11/1999 Interior Color: Grey
VIN:
220208 Exterior Color: White
License: Odometer:
CA Condition: Fair
State:
Tinted Glass Stereo Bucket Seats
TRANSMISSION
Console/Storage Search/Seek WHEELS
Automatic Transmission
CONVENIENCE Cassette Wheel Covers
POWER
Intermittent Wipers SAFETY PAINT
Power Steering
Rear Window Wiper Drivers Side Air Bag Clear Coat Paint Power Brakes
RADIO Passenger Air Bag
DECOR
Dual Mirrors AM Radio SEATS
Body Side Moldings FM Radio Cloth Seats
447084 | 1.8.07.10200
10/27/20224:58:13PM
C P Y
Owner: Spagna, Francisco
COGSONE. MARKET VALUATION REPORT Claim: 2212399053801
000055 9/11
COMPARABLE VEHICLES
COMPARABLE VEHICLE SUMMARY The following comparable vehicles) were used to determine this Base
Source Comparable Vehicle Price Adjusted Comp Vehicle Value by computing the Value arithmetic average of the adjusted
values of the comparable vehicles.
1 Dealer Vehicle 2000 Plymouth Voyager $4,399 $ 3,347
Details on these comparable vehicles
113" Wb 4 2.4l Gasoline (List)
are in the Comparable Vehicles section.
Smpi
2 Dealer Vehicle 2000 Plymouth Voyager $ 2,999 $ 1,653
Se 113" Wb 6 3.3l Flex (List)
Fuel Smpi
Base Vehicle Value $ 2,500.00
© Copyright 2021 CCC Intelligent Solutions Inc. All Rights Reserved.
C O Y
Owner: Spagna, Francisco
COGSONE. MARKET VALUATION REPORT Claim: 2212399053801
VALUATION NOTES
11/10/2022 17:55 - Refurbishments changed after request Disposed Regulations concerning vehicle value
11/10/2022 17:55 - Refurbishment Maintenance Item Changed: Purchase Price Old: include California Code of Regulations $551.00 Purchase Price New: $25.00 Date Old: 07/01/2022 Date New: 08/01/2022 10 CA ADC 2695. 11/10/2022 17:55 - Refurbishment Maintenance Item Changed: Purchase Price Old:
$551.00 Purchase Price New: $467.00 Date Old: 07/01/2022 Date New: 06/01/2022 11/10/2022 17:55 - Refurbishment Maintenance Item Changed: Purchase Price Old:
$551.00 Purchase Price New: $1,343.00 Date New: 07/01/2022 11/10/2022 17:51 - Refurbishments changed after request Disposed 11/10/2022 17:51 - Refurbishment Maintenance Item Changed: Purchase Price Old: NIL Purchase Price New: $467.00 Date Old: NIL Date New: 06/01/2022 11/10/2022 17:51 - Refurbishment Maintenance Item Changed: Purchase Price Old: NIL Purchase Price New: $551.00 Date Old: NIL Date New: 07/01/2022 11/10/2022 17:51 - Refurbishment Maintenance Item Changed: Purchase Price Old: NIL Purchase Price New: $25.00 Date Old: NIL Date New: 08/01/2022 This Market Valuation Report has been prepared exclusively for use by INFINITY INSURANCE COMPANY, and no other person or entity is entitled to or should rely upon this Market Valuation Report and/or any of its contents. CCC is one source of vehicle valuations, and there are other valuation sources available.
© Copyright 2021CCC Intelligent Solutions Inc. All Rights Reserved.
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