•
MERCURY CITY OF RIALTO P.O. Box 10730
Santa Ana, CA 92711-0730
INSURANCE 2023 JAN 17 AMI|: 38 888-917-6372
RECEIVED
CITY CLERK
January 12, 2023
City of Rialto
City Clerk's Office 150S Palm Ave
Rialto, CA 92376
RE: OUR INSURED: GERARDO HERNANDEZ
OUR CLAIM NUMBER: CAPA-01925522
DATE OF LOSS: JUNE 30, 2022
YOUR INSURED:
YOUR FILE NUMBER:
DEAR City of Rialto:
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 $4,534.01
Deductible $500.00
Supplements
Rental Expense
Out of Pocket Expense
Other
Salvage
VLF, if applicable
Total $5,034.01
Total Amount Due $5,034.01
Other:
Please review our demand. Thank you.
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 final settlement" or similar wording, whether on the payment itself or on accompanying correspondence, does not function as a 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
Sandra Vila
Claims Department
888-917-6372, ext. 25577
Encl.
C21 04/2021
CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN 17 AMII: 38
TO PERSON OR PROPERTY
RECEIVED
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:
Mercury Insurance for Gerardo Hernandez
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
PO Box 10730 Santa Ana CA 92711
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Business address reference
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Claim number Capa-01925522
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 06/30/2022 TIME: 9:00 VAM O 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.
DRIVING DOWN ALDER AVE CONSTRUCTION WAS BEING DONE AND NO WAY TO EXIT WENT THROUGH
AND CEMENT AND PAVEMENT WAS UNEVEN CAUSING DAMAGE TO THE VEHICLE
3. HOW DID DAMAGE OR INJURY OCCUR?
CITY WAS DOING CONSTRUCTION THERE WAS A LOT OF UNEVEN PAVEMENT WHICH CAUSED DAMAGE IO OUR INSURED'S VEHICLE LOWER ARMS, RODS AND PAINT.
4. WERE POLICE AT THE SCENE? COYES NO WERE PARAMEDICS AT THE SCENE? [YESNO
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.
The city should have closed the street down due to uneven pavement and rocks on the street.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ $5034.01 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Repair estimate Amount: $$5034.01
Item/Date: Amount: $
•
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $5034.01 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: S
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: NAME:
ADDRESS: ADDRESS:
TELEPHONE: () TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE:
DATE: TIME: 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 AFFELERK CEIP 2023 JAN 17 AMII: 38 CITY OF RIALTO
PARKWAY
//F SIDEWALK
THAVE READ THE ENE TEEN TINA LEAN AS THESE MATES ELEVE THEM TO BE REXCEPT AS TO *LARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. on behalf of Mercury Insurance
SIGNATURE OF CLAIMANT OR AGENT
Sandra Vila 11/23/2022
TYPE OR PRINT NAME DATE
subrogation adjuster for insurance company
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 AVALON COLLISION CENTER - FONTANA Estimate ID
15090 HILTON DR, Fontana, CA 92336 11133329
Office: (909) 452-7578
Fax: (909) 452-7550 Quote ID
109978868
[email protected] Claim Number
EPA: CAL000428739 License: 055885 Tax ID: 460616137 CAPA-0192552200101 Owner Insured Appraiser
GERARDO HERNANDEZ GERARDO HERNANDEZ David Nava
FONTANA, CA 92335
Classification
None
Supplemented By
David Nava
Classification
None
MERCURY INSURANCE GROUP
Loss Type Claim Number Policy Number Adjuster
Comprehensive CAPA-0192552200101 040118190232922 Michelle Morales (888) 263-7287+22945 (Wor
Deductible Reported Date Loss Date Inspection Site
500.00 - Not Waived 08/01/2022 06/30/2022 CARSTARAVALON COLLISI
ON FONTANA
15090 HILTON DR
FONTANA, CA 92336-4020
Repair Facility
AVALON COLLISION CENTE
R-FONTANA
15090 HILTON DR
Fontana, CA 92336
2009 Lincoln MKS 4 Door Sedan 3.7L 6 Cyl Gas Injected 6 Speed Auto Trans FWD Exterior Color Interior Color License VIN
WS (White Suede) BLK CA-8YGY492 1LNHM93R19G630891
Condition Drivable Odometer Production Date
Good Yes 160330 03/2009
Mitchell Service Code
911123
Primary Point of Impact
Front (12)
Committs On Version Mitchell Cloud Estimating™ Printed On Profile Page 1 of 9 8/23/2022 Mitchell Estimating 22,2 Copyright 1994-2022 Mitchell International, Inc. 8/23/2022 Mercury Insurance 09:41 AM 09:41 AM Profile Version
All Right's Reserved
12.0 Options
Air Conditioning Alum/Alloy Wheels AM-FM Stereo Anti-Lock Brake Sys. (ABS) Auto Air Condition Automatic Headlights Auxiliary Input Bluetooth Wireless CD Player CD Player (Multi) Connectivity
Cruise Control Driver Seat With Power Driver-Front Air Bag Dual A/C Electric Defogger Lumbar Support
Electronic Parking Aid Electronic Stability Control Exterior Memory Mirrors First Row Bucket Seat Fog Lights Front Cooled Seats Front Heated Seats Front Seats With Power Genuine Wood Trim Heated Mirror Lumbar Support
Heated Seats High Intensity Discharge Interior Automatic Keyless Entry System Leather Seats Headlights Day/Night Or
Electrochromatic Mirror
Left-Curtain Air Bag Memory Seats MP3 Player Passenger-Front Air Bag Power Door Locks Power Driver Seat Power Passenger Seat Power Remote Mirror Power Steering Power Windows Rear Bench Seat Rollover Protection System Satellite Radio Second Row Side Airbag With Side Airbags Head Protection
Steering Wheel Mounted Telematic Systems Theft Deterrent Sys. Tilt Steering Wheel Tire Pressure Monitoring Audio Control System
Traction Control Electronic Universal Garage Door
Opener
GERARDO HERNANDEZ | 2009 Lincoln MKS
Parts Profile Parts Profile Version
CA CARS Shop Profile 30.0
LABOR PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax Front Bumper
1 101453 Frt Bumper Cover Assy Overhaul Body 2.7# 2.7 Existing 2 100013 Frt Bumper Cover Remove / Body INC# 2.7 Remanufacture FO1000638R 1 $438.00 Replace
3 900501 ROCK CHIPS ACROSS
ENTIRE BUMPER
4 AUTO Frt Bumper Cover Refinish Refinish 2.7C 2.7
Only
5 100014 R Frt Lwr Bumper Panel Remove / Body INC# 0.3 OEM BASZ 17626 1 $48.45 Yes Replace AA
6 100015 L Frt Lwr Bumper Panel Remove Bod INC# 0.3 OEM 8A5Z 17626 1 $54.57 Yes AB
7 100016 Frt Bumper Emblem Remove / Body INC# 0.2 OEM 8A5Z 8213 1 $63.58 Yes Replace AA
в 100006 Frt Bumper Air Deflector Remove / Body INC 0.4 OEM 8A5Z8327 A 1 $83.92 Yes Replace
9 900501 TEXTURED LOWER, N/A
KEYSTONE REF#
C0333562, LKQ. CORP
32767636, METRO
DISTR NA # 29491
10 100019 Frt Lwr Bumper Grille Remove / Body INC# 0.4 OEM 8ASZ 17K945 1 $419.40 Yes
Replace CB
11 900501 UNABLE TO LOCATE
ALT PART, N/A
KEYSTONE REF#
C0333562, LKQ. CORP
32767636, METRO
DISTRNA # 29491
Committed On Version Printed On Profile
8/23/2022 tchell Estimating 2: Mitchell Cloud Estimating™ Page 2 ofs Copyright 1994-2022 Mitchell International, Inc 8/23/2022 Mercury Insurance 09:41 AM MAUG 22 09:41 AM Profile Version
All Rights Reserved 12.0
LABOR -- - - PART
Line# Description Operation Type Total Units CEG Type Number Qty Total Price Tax 12 AUTO Frt Bumper Cover Remove / Body INC 1.3
Install
Grille
13 100026 Grille Remove / Body INC# 0.4 Qual Recycled 1 $470.00* Yes Replace Part
14 900510 Line Markup 20.0% $94.00
15 900501 LKQ CORP REF
#32767636
16 100027 Grille Opening Remove / Body. INCr# 0.4 Existing Reinforcement Install
Front Lamps
17 101457 R Front Combination Remove / Body INC# 0.4 Existing Lamp Install
18 101458 L Front Combination Lamp Remove / Body INC# 0.4 Existing Install
19 103237 R Frt Combination Lamp Remove / Body 0.6# 0.6 Remanufacture F0250327OR 1 $384.00 Replace
20 900501 LT AND RT LAMPS HAVE
ROCK CHIPS ACROSS
LENSES
21 AUTO Headlamps Check / Body 0.5 0,5
Adjust
22 103238 L Frt Combination Lamp Remove / Body 0.6# 0.6 Qual Recycled 12648 1 $600.00 Yes Replace Part
23 900510 Line Markup 20.0% $120.00
24 100052 RErt Fog Lamp Bezel Remove / Body INC# 0.3 OEM 8A5Z 15266 1 $185.00 Yes Replace AA
25 900501 N/A KEYSTONE REF#
C0333562, LKQ CORP
32767636, METRO
DISTR NA #29491
26 100053 L Frt Fog Lamp Bezel Remove / Body INC# 0.3 OEM 8A5Z 15266 1 $185.00 Yes Replace BA
27 100051 R Frt Fog Lamp Assembly Replace! Body INC# 0.3 Aftermarket FO2590110C 1 $82.00 Yes Certified
28 AUTO Fog Lamps Check/ Body 0.4 0.4
Adjust
29100055 L Frt Fog Lamp Assembly Remove / Body INC# 0.3 Aftermarket FO2590110C 1 $82.00 Yes Replace Certified
Hood
30 100060 Hood Panel (Alum) Repair Body 4.0° 1.5 Existing 31 AUTO Hood Outside Refinish Refinish 2.7 C 2.7 Existing Only
Front Fender
32 100145 RFender Panel Repair Body 2.0*# 2.9 Existing
33 AUTO RFender Outside Refinish Refinish 1.7 C 2.1 Existing Only
34 100146 L Fender Panel Repair Body 2.0*# 2.9 Existing 35 AUTO L Fender Outside Refinish Refinish 1.7 C 2.1 Existing Only
36 100139 R Fender Liner Remove / Body 0.4r 0.4 Existing Install
37 100140 L Fender Liner Remove / Body 0.4r 0.4 Existing Install
Additional Costs & Materials
Committed On Version Mitchell Cloud Estimating™ Frinted On Profile Page 3 of9 8/23/2022 Mitchell Estimating 222 Copyright 1994-2022 Mitchell International, Inc. 8/23/2022 Mercury Insurance 09:41 AM All Rights Reserved 09:41 AM Profile Version
12.0 LABOR — -. PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax 38 AUTO Paint/Materials Additional $395.20" Yes
Cost
Additional Operations
39 AUTO Clear Coat Additional Refinish 2.3 0.0 $0.00
Operation
Special / Manual Entry
40 900500 Tint Color Additional Body* 0.5* 0.0 Existing Labor
41 900500 Mask for Overspray Remove / Body® 0.0* 0.0 Aftermarket 1 $9.26* Yes Replace New
42 900500 Basecoat Reduction LT Refinish Refinish* -0.2° 0.0 Existing FENDER Only
43 900500 Basecoat Reduction RT Refinish Refinish* -0.2* 0.0 Existing Fender Only
44 900500 Basecoat Reduction Hood Refinish Refinish* -0.3* 0.0 Existing Only
* Judginent 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
d Discontinued by Manufacturer
OEM Original Equipment Manufacturer
Parts Vendors
KEYSTONE MERC KEYSIQ KEYSTONE MERC KEYSIQ
15895 VALLEY BLVD. #100 13603 FOSTER RD.
FONTANA CA 91761 SANTA FE SPRINGS CA 90670
(800) 421-7866 (Work) (562) 364-1202 (Work)
(909) 986-4586 (Work) (800) 243-4340 (Work)
Part # Total Total
Line Line Part #
Price Price
27 FO2590110C $82.00 2 FO1000638R $438.00
KEYSTONE-INS QUALITY PRT
15895 VALLEY BLVD. #100
FONTANA CA 91761
(800) 421-7866 (Work)
(909) 986-4586 (Work)
Line Part # Total
Price
19 FO2503270R $384.00
29 FO2590110C $82.00
Recycled Part Vendors
Crown Auto Salvage, Inc.
1450 Magnolia Ave
Corona CA 92879
(951) 737-2823 (Work)
(951) 270-2689 (Work)
Committed O Version Mitchell Cloud Estimating™ Printed On Profile Page 4 of 9 8/23/2022 Mitchell Estimating 22.2 Copyright 1994-2022 Mitchell International, Inc. 8/23/2022 Mercury Insurance 09:41AM OEM AUG 22 V 09:41 AM Profile Version
All Rights Reserved 12.0
Line Part # Total Price Vehicle Description VIN
22 12648 $600.00 2011 Lincoln MKS L. 1LNHL9DR3BG614246
Supplier Notes: (xenon, HID), (adaptive headlamps), brig Disclaimer: Recycled part pricing may represent either actual pricing (the price at which the recycler is willing to sell the part for in its existing condition) or undamaged pricing (the price at which the recycler would sell the part if it was in undamaged condition). If you are unsure, please contact the automotive recycler. Some parts located for this quote may be interchangeable but may not be an exact match. If you are unsure, please contact the automotive recycler.
Estimate Totals
Labor Units Rate Sublet Add'l Amount Totals
Body Labor 14.1 $47.00 $662.70
Refinish Labor 10.4 $47.00 $488.80
Total Labor 24.5 $1,151.50
Taxable $0.00
Tax 0.0000% $0.00
Non-Taxable $1,151.50
Labor Total $1,151.50
Parts Amount
Taxable Parts $2,283.18 $2,283.18
Parts Adjustments $162.00
Tax 7.7500% $189.50
Non-Taxable $822.00
Parts Total $3,456.68
Costs Amount
Other Additional Costs $0.00 $0.00
Paint Materials $395.20 $395.20
Taxable $395.20
Paint Materials Rate: $38.00 Tax 7.7500% $30.63
Rate Max: 99.9 units Non-Taxable $0.00
Additional Rate: $0.00 Costs Total $425.83
Gross Totals Amount
Gross Total $5,034.01 $5,034.01
Taxable $2,840.38
Tax $220.13
Non-Taxable $1,973.50
Gross Total $5,034.01
Adjustments Amount
Deductible -$500.00 -$500.00
Total Customer -$500.00
Responsibility
Net Estimate Total $4,534.01
Less Original Net Total $4,619.01
Net Supplement Amount -$85.00
S1: David Nava -$85.00
Committed On Version Primed On Profile
8/23/2022 Mitchell Cloud Estimating™M Page 5 of 9
Mitchell Estimating 22.2 8/23/2022 Mercury Insurance
Copyright 1994-2022 Mitcheli International, Inc.
09:41 AM OEM AUG 22 V 09:41 AM Profile Version
All Rights Reserved
12.0 Comments:
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE
PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE.
PURSUANT TO CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5, SUBCHARTER 7.5, SECTION 2695.8 THE INSURER WARRANTS THAT ANY
NON-ORIGINAL EQUIPMENT MANUFACTURER PARTS SPECIFIED IN THE ESTIMATE
ARE AT LEAST EQUAL TO THE ORIGINAL EQUIPMENT MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT AND PERFORMANCE.
********** Inspection Summary Information ***********
Vehicle Arrival Date-08/10/22
Driven in, towed or Delivered by Road America? DRIVEN IN Date Inspected - 08/10/22
Number of business days to repair - 7 (ESTIMATE ONLY)
Copy of estimate given to customer ?YES
Send Payment to Facility? NO
Is the vehicle a Partial Loss or a Total Loss? PARTIAL LOSS *************** CARS Inspection Closing Report ************* Notes:
Were Alternate Parts available? YES
Name of Alternative Parts Reference Source? KEYSTONE
Alternative Parts Reference Phone # 800-525-3667
Estimate Event Log
Job Created 8/1/2022 02:21 PM
Supplement 1 Started 8/10/2022 10:18 AM
Supplement 1 Printed 8/23/2022 09:41 AM
Supplement 1 Committed 8/23/2022 09:41 AM
Estimate Version 1
Committed On Version Printed On Protile Page 6 of9
8/23/2022 Mitchell Estimating 22.2 Mitchell Cloud Estimating™ Copyright 1994-2022 Mitchell International, Inc. 8/23/2022 Mercury Insurance 09:41 AM DEMAUG_22_1 All Rights Reserved 09:41 AM Profile Version
12.0 Date: 8/23/2022 9:41:18 AM
Estimate ID: 11133329
Supplement: 1 - 8/23/2022 9:41:17 AM
Profile ID: Mercury Insurance
Supplement Delta Report
Comparison of Estimate 11133329 Supplement 0 and Supplement 1 Damage Assessed By: David Nava
Supplemented By: David Nava
Insured: GERARDO HERNANDEZ
Owner: GERARDO HERNANDEZ
Vehicle: 2009 Lincoln MKS
Date of Loss: 06/30/2022
Line Labor Line Item Part Dollar Labor CEG
Item Type Operation Description Type/Num Amount Units Unit Deleted Entries
38 Mechanical ACCESS/INSPECT R Lwr Frt Susp Control Existing Arm Assy -M Existing 0.00 0.0* 0.00
OWNER HAD RT
LOWER ARM
39 REPLACED ON HIS
OWN, PHOTOS
ATTACHED OF NEW +
OLD PARTS
47 Mechanical ADD'L LABOR Sublet
4 Wheel Align 85.00* 0.0* 0.00
Sublet
OWNER STATES THERE
IS SUSPENSION AND
48 POSSIBLE
UNDERCARRIAGE
DAMAGE
Global Changes
No Deductible, Deductible Reduction Credit, Customer Responsibility, Labor Rate, or Part Adjustment changes were made.
Amount
Committed On Version Printed On Profile
8/23/2022 Mitchell Estimating 22.2 Mitchell Cloud Estimating™ Page 7 of9 09:41 AM Copyright 1994-2022 Mitchell International, Inc. 8/23/2022 Mercury Insurance OEM AUG_22_V All Rights Reserved 09:41 AM Profile Version
12.0 Original 4,619.01
Estimate
Supplement -85.00
1 Orig Total 220.13
Tax
Supp 1 220.13
Total Tax
Net
Supplement -85.00
Amount
Net Total 4,534.01
Program Cal Data Versions
Version
SuppO 4 AUG _22_V
Supp 1 4 AUG_22_V
Software
22.2 Copyright (C) 1994 - 2022 Mitchell International
Version:
All Rights Reserved
Corninitted On Printed On Protile
Mitchell Cloud Estlmating™ Page 8 of9
8/23/2022 Mitchell Estimating 22.2 8/23/2022 Mercury Insurance Copyright 1994-2022 Mitchell International. Inc.
09:41 AM OEM AUG 22 V 09:41 AM Profile Versior.
All Rights Reserved
12.0 Desktop - Claim (CAPA-01925522) Search 7 Address Book • Administration - Vacation External Links • * (0) Pal: 040118190232922 (MIC) Insd: GERARDO HERNANDEZ DO1: 06/30/2022 Adj: Diana Mormino (Mountain Claims - Arandia) supy: Ellissette Arandia S: Closed • Check Details Up to Financials Total Incurred: 54.534.01): Summery Print Check instructions
Check Type Indemnity Recipient Margarita Hernanciez
Pay To The Order OF Margarita demandez Chesl. Batching A/P default Mailing Agdress Check Deliver, Send
$1,334.01 Check Destration Mountain Claims - Arandia
Mamo for payment resulting from your Collision claim of 06/30 2022 Printin Mailroom Yes Paymen! Tybe Contactis Tracking
Payment Method Debit Card Status Cleared
Issue Dote 09,01 2022
: Payment Details
Cleared Date 09,02/2322
it Reporting Not reportable
When To Pay 08/23 2022
Repo table Amourt N/A
Created 3y Diana Momino
Details
Created On 08 23 2322
Check flumber 8830017376
Recurrence
Bankaccount
Description N/A
invoice Number CAPA-01025:22
Total Recurrence Amount
Bulk Invoice
Claimant Margarta Hemandes Approval History
Date User: Action 3 Rationale
Date of service
03/24/2022 6:15 PM Ellissette Arandia Approved
Check Comments 2009 Lincoln tIKS
Joint Payees
Claim: CAPA-0192552200101 01 GERARDO HERNANDEZ
SE CAN MFO. BY FORD MOTOR CO
Photo 01.jpg Photo 02.jpg
MFD. BY FORD MOTOR CO
palt 17/00
TRSIG/2321
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Claim: CAPA-0192552200101 01 GERARDO HERNANDEZ
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BYCY492
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LN COLE
8XGY4,22
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Claim: CAPA-0192552200101 01 GERARDO HERNANDEZ
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Claim: CAPA-0192552200101 01 GERARDO HERNANDEZ
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