CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2022 NOV 31 AM 9: 36
TO PERSON OR PROPERTY
CITY GLERK 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)
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: 150S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Shan Yi Bass
FULL NAME MYwift
DATE OF RIDTH
voice →
Rialto, CA 92376 Iinhardot
HOME ADDRESS INCLUDING CÍTY, STATE & ZIP hearins 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: _ 11•21.22 7:20 DAM PN TIME:
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.
Coming out of crivewa make a right turn onto Riverside
Ave by walgreens, 118 E Baseline RD
Rialto, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
my bumper and fender got
4. WERE POLICE AT THE SCENE? YES DANO 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.
There should have heen Caution sien to block the
fothole or barricade. e of Riatto
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2162.82 + HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $
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) NA
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: _1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N A
NAME: _
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: | )
DATE: TIME:
•AM • PM DATE:
TIME:
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. 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 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 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
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.
CERTIFY(OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT AGENT*
han Yi Bass 12.01.22
TYPE OR PRINT NAME
DATE
elf
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 Baseline
Riverside Ave my car was damaged right here N
Curb
upwn Sidewalk
Walgreens
Store -
Stater
Bro's
Parkins store
Lot
CALIBER - RIALTO Workfile ID: da8b8be6
CALIBER Federal ID: 33-0730794
RESTORING THE RHYTHM OF YOUR LIFE State EPA: CAL000265317 BAR: ARD299767
421 West Rialto Avenue, RIALTO, CA 92376
COLLISION Phone: (909) 874-4470
FAX: (909) 874-4561
Estimate
RO Number:
Customer: Insurance: Adjuster: Estimator: Miguel Hernandez Bass, Shan CUSTOMER PAY Phone: Create Date: 12/1/2022
Claim:
Loss Date:
Deductible:
2020 HOND Accord Sedan Sport Automatic 4D SED 4-2.0L Turbocharged Gasoline Gasoline Direct Injection black VIN: Interior Color: black Mileage In: 57,395 Vehicle Out:
License: Exterior Color: black Mileage Out:
State: CA Production Date: 2/2020 Condition: Job #:
Line Ver Operation Description Qty Extended Part Labor $ Type Paint Price $ Type
1 E01 FRONT BUMPER & GRILLE
2 E01 Remove/Install R&l bumper cover 132.60 Body
3 E01 Repair Bumper cover w/o prk sensor 273.00 Body 202.80 NOTE: VARIOUS SCRAPES ACROSS UNDERSIDE NEED TO RESHAPE
BUMPER AND FEATHER EDGE/PRIME***
4 E01 Add for Clear Coat 78.00
5 E01 Remove/Replace RT Side support 1 4.80T OEM 7.80 Body 6 E01 Remove/Install License frame 15.60 Body
7 E01 VEHICLE DIAGNOSTICS
8 E01 Pre-repair scan 1 40.00 Other 39.00 Body
9 E01 Post-repair scan 1 80.00 Other 39.00 Body
10 E01 Sublet Static Calibration - Adaptive Cruise Control - Lidar/Dopple600.00 Sublet NOTE: PENDING INVOICE***
11 E01 MISCELLANEOUS OPERATIONS
12 E01 Remove/Replace Cover car/bag OEM 15.60 Body
13 E01 Adhesion Promoter 1 15.00T Other 7.80 Body
14 E01 Flex Additive 1 12.00T Other
15 E01 Remove/Replace Primer 1 15.00T Other 23.40 Body
16 E01 Mask for Primer 1 12.00 Other 23.40 Body
E01 DeNib and Polish 1 18.00 Other 78.00 Body
18 E01 Refinish Color Tint 39.00
19 E01
20 E01 PARTS PRICE SUBJECT TO CHANGE
(PER DEALER***
E01
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 Quallty or Used, Diag = Diagnostic, Elec = Electrical, Mech = 12/1/2022 9:14:52 AM Page 1
Estimate
RO Number:
2020 HOND Accord Sedan Sport Automatic 4D SED 4-2.0L Turbocharged Gasoline Gasoline Direct Injection black 22 E01 ESTIMATE SUBJECT TO CHANGE DUE
TO "ONE TIME USE"
23 E01 CLIPS, RIVETS & PLASTIC COMPONENTS
(PER DEALER***
24 E01
25 E01 THIS IS NOT A FINAL ESTIMATE ***
Estimate Totals Discount $ Markup $ Rate $ Total $
Parts 196.80
Sublet/Miscellaneous 120.00 720.00
Labor, Body 78.00 655.20
Labor, Refinish 78.00 319.80
Material, Paint 56.00 229.60
E.P.C. 20.00
Subtotal 2,141.40
Sales Tax 21.42
Grand Total 2,162.82
Net Total 2,162.82
Estimate Version Total $
Original 2,162.82
Insurance Total $: 2,162.82
Received from Insurance $: 0.00
Balance due from Insurance $: 2,162.82
Customer Total $: 0.00
Received from Customer $: 0.00
Balance due from Customer $: 0.00
"TERMS & CONDITIONS OF REPAIR SERVICES
1.Payment Upon Completion and Authority to Endorse Checks. Customer agrees that he/she is fully responsible & liable for timely payment of all charges for labor, parts, material & accessories, sublet repairs, & any other charges incurred under these Terms & Conditions, and payment in full shall be made prior to the release of the vehicle. To facilitate timely payment, Customer hereby authorizes Caliber & its authorized employees, to act in Customer's place for the purpose of endorsing, on Customer's behalf, all insurance checks made payable to Caliber and Customer, or to Customer,regarding authorized repairs to the vehicle described in this agreement with such limited authorization terminating upon full payment for the
2.Additional Repairs.Customer may authorize Caliber to conduct additional repairs that are discovered following closer inspection or disassembly orally, in written form,or via electronic messaging & all such additional repairs shall be listed on the final invoice.
3.Sublet Repairs,Repair Location and Authority to Operate Vehicle.Customer acknowledges & authorizes Caliber, including its subcontractors & employees, as Caliber deems appropriate, to: perform portions of the repairs through use of subcontractors) hired by Caliber; conduct repairs at another Caliber facility; and, operate the vehicle, including use on public streets, for the purposes of including, but not limited to, inspecting, testing, pick-up, delivery,&facilitating repairs.
4.Damage or Theft. Customer acknowledges and agrees that Caliber is not responsible for & does not accept any liability for the theft, or damage to, 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
12/1/2022 9:14:52 AM Page 2
Estimate
RO Number:
2020 HOND Accord Sedan Sport Automatic 4D SED 4-2.0L Turbocharged Gasoline Gasoline Direct Injection black the vehicle, or any personal property left in the vehicle, that is not a direct result of Caliber's gross negligence. Customer acknowledges that said property is not insured or protected to the amount of the actual cash value thereof, or otherwise, against loss related to theft, fire or vandalism while the property remains with Caliber.Customer further acknowledges that all personal property has been removed from the vehicle, and that Caliber,its employees and its subcontractors are not responsible for inspection thereof.
5.Storage Fees&Lien Sale.Customer authorizes & acknowledges that if the vehicle is not picked up within ten (10) days after Caliber has notified the Customer that the repairs are completed, Caliber may charge daily storage fees at rates that are ordinary & customary for the area, but not to exceed $100 per day.In addition to any and all other available legal&equitable remedies, Caliber may, in accordance with applicable state law, begin lien sale proceedings & sell the vehicle by way of a public auction.
6. Partner Referrals. Customer acknowledges that Caliber has partnerships with various vehicle dealerships and that Caliber may on occasion compensate these dealership partners for referring work to Caliber, to the extent permitted by law. Note that Caliber does not pay any referral fees to towing services for delivering vehicles to Caliber for repairs.
7. DISPUTE SETTLEMENT AND ARBITRATION. CUSTOMER & CALIBER ACKNOWLEDGE AND AGREE THAT IN THE EVENT A DISPUTE OR
CONTROVERSY ARISES CONCERNING THIS AGREEMENT OR THE REPAIRS TO THE VEHICLE, CUSTOMER & CALIBER SHALL FIRST ATTEMPT IN
GOOD FAITH TO SETTLE THE DISPUTE BY MEDIATION ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION UNDER ITS CONSUMER OR COMMERCIAL MEDIATION PROCEDURES, AS APPLICABLE. IN THE EVENT THAT THE MATTER IS NOT SETTLED BY MEDIATION AS PROVIDED FOR
IN THIS PARAGRAPH, CUSTOMER & CALIBER AGREE THAT SUCH DISPUTE OR CONTROVERSY SHALL BE RESOLVED BY BINDING ARBITRATION ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION UNDER ITS CONSUMER OR COMMERCIAL ARBITRATION RULES, AS APPLICABLE.
CUSTOMER HEREBY ACKNOWLEDGES THAT A COPY OF SUCH RULES, A GUIDE TO THE APPLICABLE PROCEDURES AND INFORMATION NOTING THE NEAREST AMERICAN ARBITRATION ASSOCIATION LOCATION IS AVAILABLE FOR CUSTOMER'S REVIEW AT www.adr.org/aaa/faces/rules. CUSTOMER MAY ALSO CONTACT THE AMERICAN ARBITRATION ASSOCIATION AT 212-484-4181 or 888-855-9575. JUDGMENT ON THE ARBITRATION AWARD RENDERED BY THE ARBITRATOR MAY BE ENTERED IN ANY COURT HAVING JURISDICTION THEREOF. IF EITHER CUSTOMER OR CALIBER ELECTS TO RESOLVE A CLAIM BY ARBITRATION, THAT CLAIM SHALL BE ARBITRATED ONLY ON AN INDIVIDUAL BASIS. THERE SHALL BE NO RIGHT OR
AUTHORITY FOR ANY CLAIMS TO BE ARBITRATED ON A CLASS ACTION BASIS OR ON BASES INVOLVING CLAIMS BROUGHT IN A PURPORTED
REPRESENTATIVE CAPACITY, WHETHER ON BEHALF OF THE GENERAL PUBLIC, OTHER CALIBER CUSTOMERS OR OTHER PERSONS SIMILARLY SITUATED. NOTWITHSTANDING THE FOREGOING, CALIBER AND CUSTOMER AGREE THAT CLAIMS ARISING UNDER THE MAGNUSON-MOSS WARRANTY ACT ("MMWA"), SHALL BE MEDIATED BUT SHALL NOT BE ARBITRATED. IF MEDIATION DOES NOT RESOLVE A CLAIM UNDER THE MMWA, THE CUSTOMER MAY PURSUE THE MMWA CLAIM, AND ONLY THE MMWA CLAIM, IN COURT. ANY CLAIMS NOT UNDER THE MMWA SHALL BE ARBITRATED AS SET FORTH HEREIN. IN THE EVENT THE CUSTOMER DOES BRING AN MMWA CLAIM IN COURT, CUSTOMER AND CALIBER EXPRESSLY WAIVE THEIR RIGHT TO A TRIAL BY JURY AS TO SUCH CLAIM.
8. Limited Warranty. Subject to the obligations and exclusions below, Caliber warrants the repairs against defects in materials and workmanship for the applicable period of time set forth in Section 8(A) During such time, Caliber will repair or replace any parts which prove to be defective by reason of improper workmanship or materials without charge for parts or labor relating thereto, subject to the terms and conditions herein, including, but not limited to Section 8(C) below. All warranty repairs must be performed at one of Caliber's facilities. If the vehicle is outside Caliber's market area, the warranty repairs may be performed at any repair facility nationwide that is approved in advance by Caliber.
A. Warranty Period. Non-Transferability & Non-Assignability. Except as otherwise provided herein, Caliber warrants the repairs and paint only to Customer and for only as long as Customer owns the vehicle, but in no event for less than sixty (60) days. Customer may not expressly or implicitly transfer or assign any rights granted under this limited warranty.
B. Defects in Manufacturer's Parts, Material or Accessories. In certain instances Caliber may use parts, materials or accessories in its repairs that have been procured from third-party manufacturers and/or suppliers. In such instances, Caliber warrants such parts, materials or accessories only to the extent that the third-party manufacturer or supplier's warranties apply to Caliber.
C. Limitations and Exclusions. This limited warranty does not apply to repairs necessitated by any cause beyond the reasonable control of Caliber, including any defects, damage or malfunctions caused by or resulting from unauthorized service or parts, improper or inadequate vehicle maintenance, use for which any parts or accessories were not designed or approved, alterations, accidents, modification of repairs, subsequent repairs performed by a party other than Caliber (except as set forth in this Section 8), abuse, misuse, neglect, or acts of God. Any and all disputes related to this section shall be resolved according to the procedures set forth in Paragraph 7 above.
D. Environmental Damage. This limited warranty does not apply to damage caused by chemicals, tree sap, road salt, sand, rocks, pebbles, hail, windstorms, sun, pollution or other environmental factors or road hazards that may damage cloth, leather, plastic, wood, vinyl, paint, chrome, upholstery and/or convertible tops.
E. Waiver of Right to Return of Replaced Auto Parts. By entering into this agreement Customer waives any right to the return of auto parts replaced by Caliber and Customer agrees that all parts replaced under this limited warranty shall become the property of Caliber. If you do not wish to waive your rights to return of replaced parts, please inform the center manager before you sign this document so that we may make appropriate arrangements.
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
12/1/2022 9:14:52 AM Page 3
Estimate
RO Number:
2020 HOND Accord Sedan Sport Automatic 4D SED 4-2.0L Turbocharged Gasoline Gasoline Direct Injection black
9. DISCLAIMERS. THE FOREGOING PARAGRAPH 8 IS THE COMPLETE LIMITED WARRANTY FOR CALIBER REPAIRS AND SUPERSEDES ALL OTHER WARRANTIES AND REPRESENTATIONS, WHETHER ORAL OR WRITTEN. EXCEPT AS EXPRESSLY SET FORTH ABOVE, NO OTHER EXPRESS
WARRANTIES ARE MADE WITH RESPECT TO CALIBER REPAIRS IN NO EVENT WILL CALIBER BE LIABLE TO THE CUSTOMER OF THE VEHICLE
DESCRIBED IN THIS AGREEMENT, FOR ANY COMMERCIAL DAMAGES, EXPENSES, LOST REVENUES, LOST SAVINGS OR ANY OTHER SPECIAL,
INDIRECT INCIDENTAL OR CONSEQUENTIAL LOSSES OF A COMMERCIAL NATUREWHATSOEVER, EVEN IF CALIBER HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. TO THE EXTENT THAT ANY PART OF THIS LIMITED WARRANTY IS IN CONFLICT WITH APPLICABLE LAW, CALIBER WILL FOLLOW APPLICABLE LAW.
10. Entire Agreement, Headings, Validity. Customer acknowledges that he/she has not been induced to authorize repairs by any representation or warranty not set forth in this agreement. This is the entire agreement between Caliber & Customer, and supersedes all existing agreements and all other oral or written communication between them concerning its subject matter. This agreement may only be modified in writing, signed by Caliber & Customer, either through manual or digital signatures.
AUTHORIZATION TO REPAIR******
In the event of a disassembly authorization I understand that if I choose not to have the repairs performed, I may request reassembly. I understand and agree that it may take up to ten days from the date of this authorization for reassembly to be completed. I also understand and agree that the act of teardown/disassembly will prevent restoration of the vehicle to its original condition.
I the undersigned customer (''Customer'), authorizing repairs to the above listed vehicle on this Repair Order and hereby authorize this facility, a Caliber Collision Center (''Caliber) to make the repairs stated herein pursuant to the Terms and Conditions stated on this Repair Order.
I understand this repair estimate is a description of the work to be done, and the estimated charges for the parts, labor and materials, to repair known damage to the vehicle. During the course of repairing known damages, other damages to the vehicle may be discovered which may cost more to repair. In the event there are any additional charges, you will notify me before doing additional work, and you will obtain my authorization for the additional work.
Customer Signature: Date:
POWER OF ATTORNEY******
I Do Hereby Appoint Caliber Collision Centers As My Lawful Attorney In Fact To Accept On My Behalf Any And All Checks, Drafts, Or Bills Of Exchange, And To Endorse All Such Instruments, And Place Them In a Negotiable Position For Deposit To The Aforementioned Business' Account For Credit On My Account For Repairs On My Vehicle
DESIGNATION OF PERSON TO AUTHORIZE ADDITIONAL WORK, PARTS OR PICK-UP OF VEHICLE****** I hereby designate the individual named below to authorize any additional work not specified or parts not included in the original written estimated price for parts and labor. Said person is also authorized to pick up my vehicle:
Name of Designee: _Phone Number:
Fax Number: Email Address: _
Customer Signature: Date:
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 = 12/1/2022 9:14:52 AM Page 4
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