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Rialto City Clerk's Office
150 S Palm Ave
Rialto CA 92376-6406
CITY CLERK RECEIVED 2023 JAN 3 AMII: 13 CITY OF RIALTO
SUBROCLAIMS
December 27, 2022
Attn: Rialto City Clerk's Office
290 W. Rialto Ave.,
Rialto, CA 92376
RE: Loss Date: 11/19/2022 CITY CLERK RECEIVED
Geico Insured: Eric Alexander Mendoza
Geico Claim#: 8752802940000001
Subro Claims#: 1649832
Dear City Clerk,
Our office has been retained by Geico Insurance to help expedite payment on the above claim. Geico Insurance had already concluded their investigation of the accident and has found your insured liable for our damages.
Payment for repairs has been made. Documentation is attached. Please honor our claim.
Property Damage: $2,938.77
Rental: $ 840.00
Deductible: $1,000.00
Rental Out of Pocket: $ 115.74
Total: $4,778.77
Please make your check payable to Geico and mail it to us at the following address. 28150 N Alma School Parkway #103-642, Scottsdale, AZ 85262 Should you require any assistance in resolving this matter, please contact us at 800-949-5655 or [email protected] . Please refer to the Subro Claims number when calling about this claim.
Sincerely,
алит
Insurance Department
On Behalf of Geico
Please be advised that any payment in an amount less than that set forth in this letter that is. forwarded to SubroClaims without its prior authorization as described below will not constitute a full and final settlement and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination, unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as "payment in full" or have other words of similar meaning written on them, their processing will not constitute an accord and satisfaction, as SubroClaims/Geico has not agreed to acceptance of such payments. 28150 N Alma School Parkway #103-642, Scottsdale, AZ 85262 Tel: (800) 949-5655 Fax (408) 369-8169 Email:[email protected] https://subroclaims.com
CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 JAN 3 AMII: 12
RECEIVED
1. Claims for death, injury to person, or lo personal property must be fled not later than six (6) months after the occurrence (Gov. Code 9015.% CLERK 2: Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov: Cotte 5977-2). 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:
Subro Claims, Inc o/b/o Geico Ins a/s/o Eric Alexander Mendoza
FULL NAME DATE OF BIRTH
28150 N Alma School Pkwy #103-642 Scottsdale, AZ 85262 (800) 949-5655 HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
Subro Claims, Ine o/blo Geico Ins
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 28150 N Alma School Pkwy #103-642 Scottsdale, AZ 85262
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 11/19/2022 TIME: 2:20am • AM OPM
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. 1660 N Linden Ave, Rialto, CA, 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Unsecured Plastic Barrier flew into insured driver side fender/bumper
4. WERE POLICE AT THE SCENE? DYES ONO 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.
No injuries.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 4,778.77 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: coll Amount: $ 3,938.77
Item/Date: rental Amount: $ 840.00
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 4778,70 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $_
Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 4778-70
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
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: • AM D]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 "Be 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. 2023 JAN
RECEI CITY OF RIALTO
CURB CITY CLERK
PARKWAY $11: 12
SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Wendy Gallets 12/27/22
TYPE OR PRINT NAME
DATE
on behalf of Gerco Ins
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
CITY OF RIALTO
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