CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 FEB - 7 AMII: 16
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:
Allstate Ins Co a/s/o Jonathan Garcia NA
-
FULL NAME DATE OF BIRTH
San Bernardino, CA 92410
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Allstate Ins Co a/s/o Jonathan Garcia P.O. Box 660636 Dallas, TX 75266 (972) 871-4553 BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Allstate Ins Co a/s/o Jonathan Garcia/0696437250
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): P.O. Box 660636 Dallas, TX 75266
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 12/20/2022 TIME: 7:38
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.
Damages occurred in the parking lot of 1276S Riverside Ave in Rialto, CA.
3. HOW DID DAMAGE OR INJURY OCCUR?
Allstate insured's motorcycle was parked and unoccupied at the Rialto Marketplace when a Rialto Police Dept driver backed into the Allstate insured's motorcycle causing damages.
4. WERE POLICE AT THE SCENE? MYES • NO WERE PARAMEDICS AT THE SCENE? •YES D/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.
Rialto Police Dept driver is currently unknown. The Police vehicle license plate is 1387216, it was a 2013 ford Taurus. The police driver backed into the Allstate insured's parked and unoccupied motorcycle. Rialto Police Report # 932215060
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 959.44 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Auto damages paid by Allstate Ins Co Amount: $459.44 Item/Date: Allstate insured paid their deductible Amount: $ 500.00 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 959.44 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: NA
Amount: $_
Item/Date: NA
Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ NA
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: None NAME: NA
ADDRESS:
ADDRESS:
TELEPHONE: ()
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: No injuries NAME: NA
ADDRESS: ADDRESS:
TELEPHONE: ( ) TELEPHONE: L
DATE: TIME: • AM •] 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 comers. f 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 vehicl 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
PARKWAY
SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Esmeraida Moreno 127/2023
TYPE OR PRINT NAME DATE
Insurer
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