CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES JAN 3
TO PERSON OR PROPERTY
PM
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). F 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:
Cullermina Negrete Mendez -
FULL NAME DATE OF BIRTH
RIALTO CA 92376
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: 10/12/22 TIME: 3:30 DAM 0 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.
Randall and pepper ed at a yellows light
I was stopped
3. HOW DID DAMAGE OR INJURY OCCUR?
I was stopped at the light while it was on yellow
that is when I was hit from behind
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? YES LT 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.
Back bumper was damaged
The tail light on the left is broken
The front windshield Cracked due to the hard hit
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $1,919.60 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 1/3/23 Amount: § 1,919. 60
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $1.$10.42 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $
Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 1,810.42
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Herberto Verdurio NAME: Zapata, Mex
82336
ADDRESS: ADDRESS: police Rialto
RIALTO CA 923TG Sargento smit
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:
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 Randall #Pepper
PARKWAY
7. SIDEWALK
THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T I1 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Gullermina Negrete Mender 1|3/23
TYPE OR PRINT NAME
DATE
myself
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 Sebastian Carvajal
• 1364 Camino Real, San Bernardino, CA. Unit 100
C +1 951 376 9883
• [email protected] Royal Road Collsion Center Estimate
ROYAL ROAD 1364 Camino Real
San Bernardino, CA 92408 Rear Collision
COLLISION CENTER Est # 1096
siness Phone: (951) 376-9883
@royalroadcollisioncenter.com ID#12743726
IT STUN CENTER
Dwner Insurance Company
Guillermina Nearete Shop Info
Inspection Date: 12/23/2022 Estimators Phone: (951) 329-2314 Repair Days: 3 Estimators Email:
Body Type: 4 Door Utility [email protected] Engine: 4.7L 8 Cyl Gas Injected
Drive Type: 2WD
Oper Description Part Number
Price Labor
WINDSHIELD
Replace W/SHIELD GLASS
56101-0C031 $815.14 3.5 hrs. Glass
2 Replace LWR W/SHIELD WEATHERSTRIP ORDER FROM
$18.16
DEALER
3 Replace UPR W/SHIELD WEATHERSTRIP
ORDER FROM $6.49
DEALER
4 R&l UPR WISHIELD MOULDING
5 R&I W/SHIELD REAR VIEW MIRROR 0.2 hrs. Body
REAR DOOR 0.2 hrs. Body
6 Biend L REAR DOOR WHEEL OPENING FLARE
0.3 hrs. Blend
QUARTER PANEL 0.3 hrs. Refinish
7 Repair L QUARTER WHEEL OPENING FLARE
REAR BUMPER 1 hrs. Body
8 Repair L REAR BUMPER WHEEL OPENING
FLARE 0.8 hrs. Body
0.2 hrs. Clearcoat 0.5 hrs. Paint panel
0.2 hrs. Refinish
Repair REAR BUMPER COVER
1 hrs. Body
1.3 hrs. Clearcoat 3.2 hrs. Paint panel
1.3 hrs. Refinish
Totals
Type Labor Time Cost
Total Taxable
Body Labor 3.2 $70.00 $224.00 2023 JAN "3
Glass Labor 3.5 $52.00 $182,00
Paint Labor 5.5 $70.00 $385.00 CITY CLERK RECEIVED
Paint Supplies 5.5 $36.00 $198.00 CITY OF RIALTO
OEM Parts $839.79
Taxable Amount PM 1:41
$1,037.79
Tax 8.75%
$90.81
Nontaxable Amount $791.00
Grand Total $1,919.60
Powered By Web-Est 1012
12/23/2022 3:42 PM
Wyatt's Paint & Body Workfile ID: a9dd8f04
PartsShare: 77b3xL
f We Can't Fix Your Car, Nobody Car State EPA: CAL000355162 Magell's 350 N. Rancho Ave, San Bernardino, CA 92410Y OF RIALTO BAR: ARD00064132
Phone: (909) 885-5051
FAX: (909) 884-0889 2023 JAN 3 PM |: 41
Estimate RECEIVED
CITYCLERK
RO Number:
Customer: Insurance: Adjuster: Estimator: Kris Wyatt
Negrete, Guillermina Phone: Create Date: 12/23/2022
Claim:
Loss Date:
Deductible:
2003 TOYO Sequoia SR5 4D UTV 8-4.7L Gasoline SFI
VIN: 5TDZT34A33S201735 Interior Color: Mileage In: Vehicle Out:
License: Exterior Color: Mileage Out:
State: CA Production Date: Condition: Job #:
Line Ver Operation Description Qty Extended Part Labor Type Paint Price$ Type
1 E01 WINDSHIELD
E01 Remove/Replace Windshield NAGS 249.85T Glass 3.7 Body 3 E01 Remove/Replace Dam long 18.16T OEM
4 E01 REAR LAMPS
5 E01 Remove/Replace LT Tail lamp assy 126.13T A/M 0.3 Body E01 REAR BUMPER
7 E01 Overhaul 0/H bumper assy OEM 1.8 Body
8 E01 Remove/Install LT Flare 0.0 Body
9 E01 Repair LT Flare 1.0 Body 0.5
10 E01 Add for Clear Coat 0.1
11 E01 Repair Bumper cover w/flare 2.0 Body 3.0
12 E01 Add for Clear Coat 12
13 E01 Sublet Hazardous waste removal 1 5.00T Other
14 E01 Repair Color tint / color match 0.5
15 E01 Repair Color sand and buff
16 E01 Remove/Replace Flex additive 1 7.00T Other
Estimate Totals Discount $ Markup $ Rate $ Total Hours Total $ Parts 401.14
Sublet/Miscellaneous 5.00
Labor, Body 75.00 8.8 660.00
Labor, Refinish 75.00 53 397.50
Material, Paint 54.00 5.3 286.20
Subtotal 1,749.84
= Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman :
Vechanical, Re Rem ne, true a Stretament Manufacturer, Recor = Re cored, RECOND = Recondioned, UK = Like nd Quality or used, Drag = Diagnost, Ee = Electical, Mech - 12/23/2022 1:44:29 PM Page 1
1.. Estimate
RO Number:
2003 TOYO Sequoia SR5 4D UTV 8-4.7L Gasoline SFI
Sales Tax 60.58
Grand Total 1,810.42
Net Total 1,810.42
Estimate Version Total $
Original 1,810.42
Insurance Total $: 0.00
Received from Insurance $: 0.00
Balance due from Insurance $: 0.00
Customer Total $: 1,810.42
Received from Customer $: 0.00
Balance due from Customer $: 1,810.42
REPAIR OR WORK AUTHORIZATION / POWER OF ATTORNEY
TEAR DOWN AUTHORIZATION
Cash, Cashier's Check, Credit Card or Money Order only. NO CHECKS! Estimates of repair include all parts, labor, handling and diagnosis. If on closer inspection it is found that additional repairs are necessary, you will be contacted for authorization to proceed. If automobile is returned to customer before authorized services are performed, a diagnostic and handling charge not including reassembly will be made if applicable. 1 authorize Wyatt's paint & Body to act as my agent in negotiating the final cost of repairs with my Insurance Company.
I hereby authorize the repair work described herein to be performed, including sublet work, and grant you or your employee's permission to operate the vehicle on streets or highways for the purpose of repairing or testing and acknowledge receipt of this estimate.
I UNDERSTAND THAT I AM RESPONSIBLE FOR THE PAYMENT OF THE COST OF SAID REPAIRS and agree that in the event any legal action is required I will also pay such additional amounts that the court may charge and/or attorney fees. If an insurance claim, the undersigned does hereby constitute and appoint Wyatt's paint & Body my true attorney to sign my name on any insurance drafts covering any authorized repairs to my automobile and to take such action as may be necessary to negotiate said drafts.
I authorize tear down and appraisal of vehicle. If vehicle is not repaired at Wyatt's paint & Body I understand there will be a charge not to exceed $500.00 for the estimate tear down and negotiations performed.
No reassembly of vehicle will be performed due to the nature of the damages.
DO NOT LEAVE ANY LOOSE ITEMS IN VEHICLE. WE ARE NOT RESPONSIBLE FOR YOUR PERSONAL ITEMS LEFT IN THE VEHICLE. PLEASE REMOVE ALL ITEMS OF VALUE FROM YOUR VEHICLE.
Tear Down Authorization : Date:
Original Estimate $:
Authorized By: 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 = Mechanical. Ref = Refinish. Struc = Structural
12/23/2022 1:44:29 PM Page 2
PARKING
PERMIT
Рорис Тонину
921.682 3602
TENANT PARKING
0122