P.O. Box 10730
MERCURY Santa Ana, CA 92711-0730
INSURANCE
November 18, 2022
City of Rialto, Clerk's Office CITY CLERK RECEIVED 2022 NOV 29 AM 9:40 CITY OF RIALTO 150 South Palm Avenue
Rialto, CA 92376
RE: OUR INSURED: SEAN HARRISON
OUR CLAIM NUMBER: CAPA-01985409
DATE OF LOSS: OCTOBER 21, 2022
YOUR INSURED:
YOUR FILE NUMBER:
Dear City of Rialto, Clerk's Office:
We have obtained information suggesting that the damages incurred from the above-referenced loss were caused by your insured's negligence.
Enclosed for your review, please find copies of our supporting documentation. The breakdown of our payments is as follows:
Initial Repairs $2,563.87
Deductible $500.00
Supplements
Rental Expense $669.34
Out of Pocket Expense
Other Towing $289.00
Salvage
VLF, if applicable
Total $4,022.21
Total Amount Due $4,022.21
Other:
Please review for payment.
If we receive a payment that is less than the amount shown above, it will be processed and applied as a partial payment only This will not indicate any acceptance of liability or agreement to compromise the claim amount. Note that "Full or fina settlement" or similar wording, whether on the payment itself or on accompanying correspondence, does not function as a release.
Should you have any questions or need additional information, please do not hesitate to contact me. Thank you for your cooperation.
Sincerely,
Mercury Insurance Company
Claims Department
888-263-7287
Encl.
C21 04/2021
CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
200 022 NOV 29
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY ECELLERK Y CLERI AM 9: 40 CITY OF RIALTO
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:
Mercury Insurance as subrogee of Sean Harrison
FULL NAME DATE OF BIRTH
(see below)
L
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Mercury Insurance, PO Box 10730, Santa Ana, CA 92711-0730 (714 ) 255-5001 -
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE same as business address
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _ 10/21/2022 TIME: 7:20 • AM LIPM
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.
Riverside Avenue and Slover Avenue in Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
Our insurred was driving southbound on Riverside Avenue and hit a pothole 2017 Toyota Tundra sustained alignment damage, suspension damage and is leaking fluids.
4. WERE POLICE AT THE SCENE? • YES X 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.
Lack of street maintenance/upkeep
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $4,022.21 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Vehicle repairs paid 11/2/2022, Towing paid 10/31 & 11/7/2022 Amount: $ 2,852.87 Item/Date: Rental paid 11/7/2022 Amount: $ 669.34
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 4,022.21 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: unknown
Amount: $_ unknown
Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ unknown
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: N/A
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: ( ) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A 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.
CURB
PARKWAY CITY CLERK
RECEIVED 2022 NOW 29 AM 9:40 CITY OF RIALTO
SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRI I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Kelly wood on behalf of Mercury insurance
SIGNATURE OF CLAIMANT OR AGENT
Kelly Wood on behalf of Mercury Insurance 11/18/2022
TYPE OR PRINT NAME DATE
insurer
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 MERCURY INSURANCE COMPANY Estimate ID
11000 EUCALYPTUS ST, RANCHO CUCAMONGA, CA 91729 11907255 Office: (909) 919-7050 Original
Fax: (909) 919-7082 Claim Number
CAPA-0198540900105
***************EMAIL ALL SUPPLEMENTS TO MY ATTENTION - [email protected]************** ***************NO SUPPLEMENTS WILL BE HONORED WITHOUT PRIOR INSPECTION OR APPROVAL**************** ***************ONLY MANUFACTURER SUGGESTED RETAIL PRICE WILL BE HONORED ON ALL PARTS*************** ***********************************CALL FILE ADJUSTER TO CONFIRM COVERAGE****************************************** All sublet labor over estimated book time labor and labor rate is subject to prior approval. All calibrations need prior approval and MUST be justified by post scan report or OEM position statement. DTC resets are included in post scan labor and calibrations.
Owner Insured
Appraiser
SEAN HARRISON SFAN HARRISON DAVID KRUG Sm CITY OF.
(909) 772-9672 (Work) N
[email protected]
Classification
Field 10 RIALTO
MERCURY INSURANCE GROUP
Loss Type Claim Number Policy Number Adjuster
Collision CAPA-0198540900105 040118190295071 Stephanie Smith (800) 521-9693+21873 (Wor
k)
Deductible Reported Date Loss Date
500.00 - Not Waived Inspection Site
10/21/2022 10/21/2022 LES SCHWAB TIRE CENTER
167 W SAN BERNADINO AV
E
Rialto, CA 92376
Inspection Date Repair Facility
11/1/2022 LES SCHWAB TIRE CENTER
167W SAN BERNADINO AV
Rialto, CA 92376
2017 Toyota Tundra SR54 Door Crew Cab 146" WB 6 Foot Bed 5.7L 8 Cyl Gas Injected 4WD Exterior Color License VIN Drivable
040 (Super White II No
Odometer Production Date Mitchell Service Code
75019 05/2017 911641
Committed On Version Printed On Profile Modified)
11/2/2022 Mitchell Estimating 22.3 Mitchell Cloud Estimating Page 1 of 4 opyright 1994-2022 Mitchell International, Ir 11/2/2022 55 RATES MIC 10:46 AM OEMOCT_22_V All Rights Reserved 10:46 AM Profile Version
9.0 Primary Point of Impact
Undercarriage (21)
2x 2022 NOV 2
Options
CITY OF RIA
4 Wheel Drive Air Conditioning AM-FM Stereo Anti-Lock Brake Sys. (ABS) Auxiliary Input Bluetooth Wireless CD Player Cloth Seat Connectivity CruiSe, Control:
Daytime Running Lights Driver-Front Air Bag Electric Defogger Electronic Stability Control First Row Split Bench Seat Fog Lights HD Radio Heated Mirror
Keyless Entry System Left-Curtain Ale Bag
MP3 Player Passenger-Front Air Bag Power Door Locks
Power Remote Mirror Power Steering
Power Windows Privacy Glass Rear Bench Seat
Rearview Camera Satellite Radio
Second Row Side Airbag With Side Airbags Skid Plate Tilt Steering Wheel Tire Pressure Monitoring Head Protection
Traction Control/Electronic System
Trailer Hitch Trip Computer
SEAN HARRISON | 2017 Toyota Tundra SR5
Parts Profile Parts Profile Version
BREAAQRP 41.0
LABOR • PART
Line # Description Operation Type Total Units Type Number Qty Total Price Tax
ABS / Brakes
1 100891 RABS Frt Sensor -M Remove / Mechanical 0.7# Aftermarket 1 $291.06* Yes
Replace New
2 100892 LABS Frt Sensor -M Remove / Mechanical 0.3# Aftermarket 1 $291.06* Yes
Replace New
Front Suspension
3 100786 R Frt Susp Hub Assy -M Remove / Mechanical 3.4# Aftermarket 1 $416.62* Yes Replace New
4 100792 R Frt Susp Hub Bearing -M Remove / Mechanical INC# Aftermarket 1 INC* Yes Replace New
5 900501 INCLUDED WITH A/M HUB
ASSY
6 100811 R Frt Susp Shock Absorber - Remove/Mechanical 1.3# Aftermarket 1 $198.99* Yes Replace New
7 100861 R Lwr Frt Susp Control Arm Remove / Mechanical 0.6# Aftermarket 1 $406.52" Yes Assy-M Replace New
Front Drive Axle
8 100834 R Frt Drive Axle Shaft Remove / Mechanical 0.3# Aftermarket 1 $340.88* Yes Assembly -M Replace New
Special / Manual Entry
9 900500 WHEEL ALIGNMENT -- 4 Additional Mechanical" 0.0* Sublet Sublet 1 $109.99* WHEELS Labor
* Judgment Item C Included in Clear Coat Calculation
T Included in Two Tone Calculation A Included in Clear Coat and Two Tone Calculation # Labor Note Applies r CEG R&R Time Used for this Labor Operation d Discontinued by Manufacturer [1 Verify the part number and price beforeordering Disclaimer: This estimate has been prepared based on the use of crash parts supplied by a source other than the manuFacturer or your motor vehear ratra ties ayticabie these replacement your are provided by the Committed On Version Printed On Profile (Modified) Page 2 of4 11/2/2022 Mitchell Estimating 22.3 Mitchell Cloud Estimating™ 11/2/2022 Copyright 1994-2022 Mitchell International, Inc 55 RATES MIC 10:46 AM OEM OCT 22 V 10:46 AM Profile Version
All Rights Reserved
9.0 Estimate Totals
Labor Units Rate Sublet Add'l Amount
Mechanical Labor Totals
6.6 $130.00 $109.99 $967.99
Total Labor 6.6 $109.99 $967.99
Taxable $0.00
Tax 0.0000% $0.00
Non-Taxable $967.99
Labor Total $967.99
Parts Amount
Taxable Parts $1,945.13 $1,945.13
Parts Adjustments $0.00
Tax 7.7500% $150.75
Non-Taxable $0.00
Parts Total $2,095.88
Costs Amount
Other Additional Costs $0.00 $0.00
Paint Materials $0.00 $0.00
Taxable $0.00
Tax 7.7500% $0.00
Non-Taxable $0.00
Costs Total $0.00
Gross Totals Amount
Gross Total $3,063.87 $3,063.87
Taxable $1,945.13
Tax $150.75
Non-Taxable $967.99
Gross Total $3,063.87
Adjustments Amount
Deductible -$500.00 -$500.00
Total Customer -$500.00
Responsibility
Net Estimate Total $2,563.87
PURSUANT TO CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5, SUBCHAPTER 7.5, SECTION 2695.8 THE INSURER WARRANTS THAT ANY 2022 NOV 29
NON-ORIGINAL EQUIPMENT MANUFACTURER PARTS SPECIFIED IN THIS ESTIMATE CITY CLERK RECEIVED CITY OF RIALTO
ARE AT LEAST EQUAL TO THE ORIGINAL EQUIPMENT MANUFACTURER PARTS IN AM 9: 40
TERMS OF KIND, QUALITY, SAFETY, FIT AND PERFORMANCE.
THIS IS NOT AN AUTHORIZATION TO REPAIR. THE UNDERSIGNED REPAIR
FACILITY AGREES TO REPAIR THIS VEHICLE USING INDUSTRY ACCEPTED
EQUIPMENT AND METHODS, AND TO COMPLETE AND GUARANTEE SAFE REPAIRS AT A PRICE OF $. _ INCLUDING ALL CHARGES. NO SUPPLEMENTS
WILL BE HONORED WITHOUT PRIOR APPROVAL.
Committed On Veron Mitchell Cloud Estimating™M Printed On Profile (Modifica
11/2/2022 Mitchell Estimating 22.3 11/2/2022 55 RATES MIC 10:46 AM OEM OCT _22_V Copyright 1994-2022 Mitchell International, Inc.
All Rights Reserved 10:46 AM Profile Version
9.0 SIGNED: _
IN THE EVENT THAT REPAIRS ARE COMMENCED, AND DURING SUCH REPAIRS IT
IS DETERMINED BY MERCURY THAT THE VEHICLE IS A TOTAL LOSS, THE
UNDERSIGNED SHOP AGREES NOT TO CHARGE STORAGE FEES FROM THE TIME THE
VEHICLE ARRIVES AT THE SHOP UNTIL THE TIME THAT REPAIRS ARE STOPPED DUETO MERCURY'S TOTAL LOSS DETERMINATION.
SIGNED:_
PRINT NAME:
All sublet labor over estimated book time labor and labor rate is subject to prior approval. All calibrations need prior approval and MUST be justified by post scan report or OEM position statement. DTC resets are included in post scan labor and calibrations.
Disclaimer: For your protection California law requires the following statement 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.
Estimate Event Log
Job Created 10/31/2022 04:10 PM
Estimate Started 11/1/2022 11:03 AM
Estimate Printed 11/2/2022 10:46 AM
Estimate Committed 11/2/2022 10:46 AM
Estimate Version
CITY CLERK RECEIVED 2022 NOV 29 AM 9:40 CITY OF RIALTO
Cornmitted On Version Mitchell Cloud Estimating™ Printed On Profile (Modified) Page 4 of 4 11/2/2022 Mitchell Estimating 22.3 Copyright 1994-2022 Mitchell International, Inc 11/2/2022 55 RATES MIC 10:46 AM OEM OCT 22 V 10:46 AM Profile Version
All Rights Reserved
9.0 Desktop Claim (CAPA-01985409) Search - Address Book Administration - Vacation External Links - Pol: 040118190295071 (MIC) Insd: SEAN HARRISON DOL: 10/21/2022 Adj: Stephanie Smith (Mountain Claims - Kinzie) Supv: Cindy Kinzie Financials (Total Incurred: $3,522.21): Summary
Scheduled Send Da Check Number * P P
Issue Date •*** Check Type * Pay To ÷ Amount * Status ÷ Bulk Invoice :
D D
10/31/2022 10/31/2022 8730269356 V D Indemnity NATION SAFE DRIVERS $116.00 Cleared 11/02/2022 11/03/2022 5502708906 Ir C LES SCHWAB TIRE CENTER Indemnity $2,563.87 Cleared
4 * 4• & SEAN HARRISON
D D
11/07/2022 11/07/2022 8730275910 V D Indemnity NATION SAFE DRIVERS $173.00 Cleared D D
11/07/2022 11/07/2022 8730276480 V D indemnity ENTERPRISE RENT-A-CAR $669.34 Cleared 076 MY 62A017202
Claim: CAPA-0198540900105 01 SEAN HARRISON
20221101104124 jpg 20221101_104132 jpg
SHOCKS
20221101104142 jpg 20221101 _ 104147 jpg
CITY CLERK RECEIVED 2022 NOV 29 AM 9:40 CITY OF RIALTO
Claim: CAPA-0198540900105 01
SEAN HARRISON
20221101104153 jpg 20221101104225 jpg
DO CRUFACTORING, TEXAS, DIC 85/17
4р ATH P255/20928 TIRES,
996
20221101_104232.jpg 20221101_104237 jpg
CITY CLERK RECEIVED 2022 NOV 29 AM 9: 40 CITY OF RIALTO Claim: CAPA-0198540900105 01 SEAN HARRISON
50 60 70
40 MPH 80
30- • 80 100,. IZ0-
- 60 km/h 90
20 •40
10i
10 -20
no. 110
RNDS
120
000 75019m 72»
20221101_104254 jpg 20221101105005 jpg
RT FRT LOWER CONTROL ARM - BALL JOINT SERVICED WITH
ARM
20221101_105308.jpg 20221101 105313 jpg
RT FRT AXLE SHAFT AXLE GREASE
CITY CLERK RECEIVED 2022 NOY 29 AM 9:40 CITY OF RIALTO
Claim: CAPA-0198540900105 01 SEAN HARRISON
20221101_105325.jpg 20221101_105329 jpg
UPD TIRE WEAR ON BOTH FRT TIRES RT FRT TIRE UPD TIRE WEAR ON BOTH FRT TIRES LT FRT TIRE CITY CLERK RECEIVED 2022 NOV 29 AM 9:40 CITY OF RIALTO
ARMS MERCURY INSURANCE SERVICES Rental Company: Enterprise Rent-A-Car Invoice: 32NBD7XDQN7
Alternate Invoice 7XDQN7
Number:
Bill To: MER32CC RENTAL DETAIL:
MERCURY INSURANCE SERVICES
Rental Period: 10/22/2022 to 11/04/2022 (14 days)
ATTN:UNIT RENTAL
Billed Period: 10/22/2022 to 11/04/2022 (14 days)
PO BOX 1150
Description Quantity Rate Amount
BREA, CA 928221150
TIME & DISTANCE 5 $42.99 $214.95
RENTER INFORMATION: TIME & DISTANCE 9 $42.99 $386.91
Renter: HARRISON, SEAN VEHICLE LICENSE
Address: RECOVERY FEE 5 $1.00 $5.00
VEHICLE LICENSE
RECOVERY FEE $1.76 $15.84
Home Phone:
Office Phone: SALES TAX 1 7.75% $46.64
RENTAL INFORMATION: Total Charges: $669.34
Rental Branch Location: Less Amount Received:
Total Amount Due: $669.34
ENTERPRISE RENT-A-CAR(32NB)
585 W VALLEY BLVD
BLOOMINGTON, CA 923162222
ADDITIONAL CLAIM INFORMATION:
Claim Number: CAPA-01985409
Claim Type: Insured
Vehicle Condition: Non-Driveable
Date Of Loss: 10/21/2022
Insured Name:
Owner's Vehicle: 2017 OTHER|TOYOTA
Department Code:
Branch/ Unit#: 2022
Policy Max Date:
Best Contact #: CITY CLERK RECEIVED
2022 NOV 29 AM 9:40 CITY OF RIALTO
Claimant # for Payment:
Date Escalated:
Application: GWCC
CARS Shop Type: Yes
Repair Facility:
LES SCHWAB TIRE CENTER
SAN BERNARDINO, CA 92376
(909) 546-3405
VEHICLES RENTED:
Effective Date Time /Year Make Model |VIN Mileage
10/22/2022 11:02 AM 2021 TOYO TACC 3TMAZ5CN5MM152549 460 10/27/2022 112:00 AM 2022 TOYO THIGH 5TDGZRAH1NS541365 11048 Rental Invoice
Please Return This Portion with Remittance
Make Payment To: Total Charges: $669.34
ENTERPRISE RENT-A-CAR (V3BD) Less Amount Received: $0.00 PO BOX 840086 Total Amount Due.... $669.34
KANSAS CITY, MO 641840086 Please Include on your Check:
Federal ID: 43-0724835 Invoice: 32NBD7XDQN7
Case Number: 11021666
InvoiceNumber: 4411477
Invoice Date: 10/25/2022
INSE Producer Code: 120568
VIN: 5TFDY5F12HX654024 Desc: 2017 TUNDRA CREWMAX S Mileage Name (Vehicle Identification Number) (Vehicle Year Model Color) SEAN HARRISON Task Id 4411477
Incident Type LDR
Provider Name D&A Towing
Provider ID 149405
Purchase Order 8807659
Disablement / Impound Business Name At or Near Scene
Disablement Address
(Location where vehicle is disabled) 983 S WILLOW AVE. RIALTO, CA 92376 Tow To Address
(Destination where vehicle is towed to) 14537 MANZANITA DR. FONTANA, CA 92335 Drop Off Delivery Date/Time 10/25/2022 11:00:00AM
Impound Reason tal Instructions: PLEASE CALL INSURED 30 MINS AHEAD OF ARRIVAL TIME SO HE CAN BE AT HIS RESII Miles To Scene
(Unloaded driving miles) 4
Miles To Scene to drop off
(Loaded driving miles) 9
SERVICED PERFORMED
Service Description
Actual service type performed in Townet system
Light Duty Recovery
ITEMIZED CHARGES
Dispatch Fee $0.00
Task LM Fee
Loaded mile fee $0.00
Task UM Fee
Unloaded mile fee $0.00
Task DM Fee
Deadhead mile fee $0.00
Task Fuel Surcharge Fee $0.00
Task Hook Fee $0.00
Impound Fee Breakup
Initial Tow $0.00
Cleanup Fee $0.00
Yard Fee $0.00
Dollies Fee $0.00 CITY CLERK KE CEIVED
Title Fee $0.00 2022 NOV 29 AM 9: 41 CITY OF RIALTO
Admin Fee $0.00
Labor Fee $0.00
Extra Miles Fee $0.00
Winching Fee $0.00
Other Fees $0.00
Benifits Over Miles s-
Storage Fee
Sum of storage per day times Days in storage $0.00
Storage Per Day $0.00
Days In Storage
Service Fee $116.00
Task Amount
Total amount for the Task Id $116.00
Total Billed Amount
Total of Task Amounts in a CaselD $116.00
THANK YOU FOR YOUR BUSINESS
Case Number: 11033351
InvoiceNumber: 4413129
Invoice Date: 10/27/2022
Producer Code: 79023
VIN: Desc: 2017 TUNDRA CREWMAX S N/A Mileage Name
(Vehicle Identification Number) (Vehicle Year Model Color) SEAN HARRISON Task Id
4413129
Incident Type LDR
Provider Name
D&A Towing
Provider ID 149405
Purchase Order
8818909
Disablement / Impound Business Name
SEIDNERS COLLISION CENTERS/FONTANA
Disablement Address
(Location where vehicle is disabled)
FONTANA, CA 92335
Tow To Address
(Destination where vehicle is towed to)
RIALTO, CA 92376
Drop Off Delivery Date/Time 10/27/2022 5:38:00PM
Impound Reason Created By Impound Portal
Miles To Scene
(Unloaded driving miles)
16 Miles To Scene to drop of
Loaded driving miles)
9 SERVICED PERFORMED
ervice Descriptior
ictual service type performed in Townet syster
Light Duty Recovery
LIEMIZED CHARGES
Dispatch Fee $0.00
Task LM Fee
Loaded mile fee $0.00
Task UM Fee
Unloaded mile fee $0.00
ask DM Fee
eadhead mile fe
$0.00
Task Fuel Surcharge Fee $0.00
Task Hook Foe $0.00
Impound Fee Breakup
Initial Tow $0.00
Cleanup Fee $0.00
Yard Fee $0.00
Dollies Fee $0.00
Title Fee $0.00
Admin Fee $0.00
Labor Fee $0.00
Extra Miles Fee $0.00
Winching Fee $0.00
Other Fees $90.00
Benifits Over Miles
Storage Fee $-
Sum of storage per day times Days in storage $0.00
Storage Per Day $0.00
Days In Storage
Service Fee $83.00
Task Amount
Total amount for the Task I $173.00
otal Billed Amount
Total of Task Amounts in a Casell $173.00
THANK YOU FOR YOUR BUSINESS
US POSTAGE PITNEY BOWE
MERCURY
INSURANCE. CITY OF RIALTO
22 92821 $ 001.68'
02 4W
0000383073 NOV 21 202:
P.O. Box 10730 Santa Ana, California 92711-0730 2022 NOV 29 AM 9:44
RECEIVED
CITY CLERK
FIRST CLASS