CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN I0 AM|: 13
TO PERSON OR PROPERTY RECEIVEL
CITY CLERK
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).
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:
Zi Huangt /Tesla Insurance Services
FULL NAME DATE OF BIRTH
Rialto, CA 92376
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Tesla Insurance JOsePLBanCITimS Adjuster
12832 Front Runner Brud Draper UT 84020 ( 801) 996-9138 BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES COMMONED LAMM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: September 07, 2022 TIME: • AM • 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.
Pepper Ave 3 victoria Ave Rialto
Zi Huang was Stopfed on north Pepper Auc When Quad Car driven by Melissa valler. Passed and made leff turn Striking rear left of the lesla
3. HOW DID DAMAGE OR INJURY OCCUR? Sec rePort
See report
4. WERE POLICE AT THE SCENE? DYES ONO 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.
See report Insured was indured/ Tesla Sustained mauor damage
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ Pends rePairs tabe HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills repair estimates, efc. Please attach 2 estimate + L 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: $ 1:7,000
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) NAME: N/A
NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: L
B. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: LL
DATE: TIME: - AM I 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".
9 NOTE: F THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
See Price report
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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SId ATURE OF CLAIMANT OR AGENT
Josuph Brown 1/4 | 2023
TYPE OR PRINT NAME
Auto Adduster Tesla Claim # CL-58-3GUUMF-1
Insurance
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 YEAR) TIME 2400) NCIC #
DAY:
OFFICER I.D.
2113 NUMBER
3609
02320
932210681
1 FACTS:
3 NOTIFICATION:
4 5 I was dispatched to a call of unknown injury collision at 2112 hours. I responded from RIVERSIDE AVE/SLOVER AVE and arrived on scene at 2120 hours. All times, speeds and measurements in this investigation are approximate.
Measurements were taken by laser, except where otherwise indicated. 10 SCENE:
11 12 At the scene of this collision, PEPPER AVE is northbound/southbound city street 13 consisting of two lanes in each direction divided by a double yellow line. The 14 roadway is straight and positive grade northbound. The surface is composed 15 primarily of asphalt. PEPPER AVE is intersected by VICTORIA AVE. VICTORIA 16 AVE is eastbound/westbound city street consisting of one lane in each direction that 17 is not divided. The roadway is straight and level. The surface is composed primarily 18 of asphalt. The intersection is no controls. See diagram. 19 20 PARTIES:
21 Party #1 (Vallez) was located on scene. Party 1 was identified by a valid CA driver's 22 23 license. Vallez was placed as a party by her own admission. 24 25 FORD EXPLORER, Driver #1's vehicle, was located on its wheels. 26 27 Party #2 (Huang) was located on scene. Party 2 was identified by a valid CA driver's 28 license. Huang was placed as a party by his own admission. 29 30 TESLA 3. Driver #2's vehicle, was located on its wheels. 31 RECEI
32 CITY CLERK
33 2023 JAN 10 AMH: 13 CITY OF RIALTO
34 PHYSICAL EVIDENCE: T LL
35 36 No physical evidence was located in the roadway.
37 38 OTHER FACTUAL INFORMATION:
39 40 Vallez was driving a marked police vehicle in Code 3 operation and her Axon Body 41 Worn camera was activated during the collision.
42 43 Huang provided four separate video clips that was captured by his Tesla. 44 45 These videos were uploaded to evidence.com
46 47 STATEMENTS:
_LISION CODING
- (Rev. 4-11) OPI 060
OFFICER 1.D. NUMBER
• (MO. DAY. YEAR) TIME (2400)
02320 932210681
2113 3609
NOTIFIED
OWNERS NAME OWNER'S ADDRESS • NO
YES
LOPERTY DAMAGE
DESCRIPTION OF DAMAGE
AIR BAG INATTENTION CODES
SEATING POSITION SAFETY EQUIPMENT A - CELLPHONE HANDHELD
CHILD RESTRAINT B - UNKNOWN
OCCUPANTS B - CELLPHONE HANDSFREE
Q - IN VEHICLE USED AIR BAG DEPLOY
1 - NONE IN VEHICLE C- ELECTRONIC EQUIPMENT
B - UNKNOWN R - IN VEHICLE NOT USED 9. RADO/ CD
S - IN VEHICLE USE UNKNOW N - OTHER E - SMOKING
D- LAP BELT NOT USED T - IN VEHICLE IMPROPER US P - NOT REQUIRED
F - EATING
1 - DRIVER E-SHOULDER HARNESS USED U - NONE IN VEHICLE EJECTED FROM VEHICL G - CHILDREN 2 TO 6 - PASSENGERS F-SHOULDER HARNESS NOT USE ANIMALS
0 - NOT EJECTED H-
4 5 7 - STATION WAGON REA - LAP/SHOULDER HARNESS OF US 1 - FULLY EJECTED PERSONAL HYGIENE 8 - REAR OCC. TRK OR 2 - PARTIALLY EJECTED J- READING
a POSHON NKNOWN J- PASSIVE RESTRAINT USED V - NO X-NO K - OTHER 0 - OTHER W- YES Y-YES 3 - UNKNOWN
PASSIVE RESTRAINT NOY U
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE MOVEMENT PRECEDING
PRIMARY COLLISION FACTOR SPECIAL INFORMATION COLLISION
TRAFFIC CONTROL DEVICES
LIST NUMBER (# OF PARTY AT FAUL A STOPPED
X A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL
VC SECTION VIOLATED B CELL PHONE HANDHELD IN USE B PROCEEDING STRAIGHT 22350 B CONTROLS NOT FUNCTIONING C RAN OFF ROAD
C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE
OTHER IMPROPER DRIVING: D CELL PHONE NOT IN USE D MAKING RIGHT TURN TO NO CONTROLS PRESENT/FACTOR" XX E MAKING LEFT TURN
TYPE OF COLLISION E SCHOOL BUS RELATEO
C OTHER THAN DRIVER* F MAKING U TURN
A HEAD - ON F 75 FT MOTORTRUCK COMBO G BACKING
D UNKNOWN'
B SIDESWIPE G 32FT TRAILER COMBO H SLOWING/STOPPING
C REAR END 1 PASSING OTHER VEHICLE
X
WEATHER (MARK 1 TO 2 ITEMS) ID BROADSIDE J CHANGING LANES XIA CLEAR E HIT OBJECT K. PARKING MANEUVER
CLOUDY F OVERTURNED L ENTERING TRAFFIC
C RAINING G VEHICLE PEDESTRIAN M OTHER UNSAFE TURNING
ID SNOWING H OTHER: N XING INTO OPPOSING LANE
E FOG/VISIBILITY FT 0 PARKED
MOTOR VEHICLE INVOLVED WITH P MERGING
OTHER*:
G WIND A NON-COLLISION Q TRAVELING WRONG WAY
LIGHTING B PEDESTRIAN R OTHER*:
X C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS)
DAYLIGHT (MARK 1 TO 2 ITEMS)
D MOTOR VEHICLE ON OTHER ROADWAY
DUSK - DAWN VO SECTION VIOLATION CITED
DARK - STREET LIGHTS E PARKED MOTOR VEHICLE
TRAIN CITED
DARK - NO STREET LIGHTS VC SECTION VIOLATION
G BICYCLE SOBRIETY - DRUG
DARK - STREET LIGHTS NOT 21806(A)(1)
ANIMAL: PHYSICAL
FUNCTIONING* VC SECTION VIOLATION CHER
ROADWAY SURFACE
XA FIXED OBJECT: XX A HAD NOT BEEN DRINKING
DRY
WET E VISION OBSCUREMENT B HBD - UNDER INFLUENCE
SNOWY - ICY J OTHER OBJECT. F INATTENTION*: C HBD - NOT UNDER INFLUENCE:
D HBD. - IMPAIRMENT UNKNOWN:
SLIPPERY (MUDDY, OILY, ETC.) G STOP & GO TRAFFIC
H ENTERING / LEAVING RAMP E UNDER DRUG INFLUENCE*
ROADMAY COMDETONS (KARK 1 TO 3 MMS) PEDESTRIAN'S ACTIONS F IMPAIRMENT - PHYSICAL 1 PREVIOUS COLLISION
X A NO PEDESTRIANS INVOLVED J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN
A HOLES, DEEP RUTS
LOOSE MATERIAL ON ROADWAY" CROSSING IN CROSSWALK DEFECTIVE VEH. EQUIP. H NOT APPLICABLE C OBSTRUCTION ON ROADWAY' AT INTERSECTION CITED SLEEPY / FATIGUED•
D CONSTRUCTION-REPAIR ZONE CROSSING IN CROSSWALK - NOT
AT INTERSECTION
REDUCED ROADWAY WIDTH L UNINVOLVED VEHICLE
D CROSSING - NOT IN CROSSWALK
FLOODED• M OTHER*:
E IN ROAD - INCLUDES SHOULDER N NONE APPARENT
"G OTHER:* F NOT IN ROAD X
TH NO UNUSUAL CONDITIONS G APPROACHING/LEAVING SCHOOL BUS O RUNAWAY VEHICLE Miscellaneous
CITY 2023 JAN 10 CITY
RECEIVEL
CLERX OF
• "See Attached Sketch"
• "See Attached factual diagram" AMI: 13 RIALTO
CONTROLLED COPY
CONFIDENTIAL COPY