CITY OF RIALTO
LIABILITY
2023 MAR 20
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED 57
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:
Michael MORalEs
FULL NAME 9241| DATE OF BIRTH
SANBERNARDINO CA
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 SINBERNADNO
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): ca 92411
1. WHEN DID DAMAGE OR INJURY OCCUR DATE: 1/9/2023 TIME: 2:45 DAMIPM
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. on pepper st in RiAto cA Right BefoRe you pAss Rialto st on ite corner oppisite sillE of ArcO GAS STATON
3. HOW DID DAMAGE OR INJURY OCCUR?
i Hit a pottole covereD in RAN QUAtER ON peppeR st iN RItitO CA caUsING daMage To My LoweR Shield and eNgine crvek
•. WERE POUCE AT THE SCENE DYES NO WERE PARAMEDIS AT THE SCENE EYES 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.
the portole on pepper st caused tHe Dtmage
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 279.34 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 279.34 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
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:
N/A NFA
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: (
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: N/A ADDRESS: N/A
TELEPHONE: _ ) TELEPHONE: |)
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 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. perfer Por rele
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. 'SERTIFY (OR DECLATE, UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Morales 3/20/2023
TYPE OR PRINT NAME DATE
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 Final Bill
RO Number: 270003316
2019 ACUR ILX 4D SED 4-2.4L Gasoline Gasoline Direct Injection Platinum White Trico 20 E01
VEHICLE DIAGNOSTICS
21 E01 Sublet
Pre-repair scan
22 E01 Repair
Scan Labor
23 E01 Sublet
Post-repair scan
24 E01 Repair
Scan Labor
Estimate Totals Discount $
Markup $ Rate $ Total Hours
Parts Total $
Labor, Body 201.46
60.00 1.2
Subtotal 72,00.
273.46
Bottomline Discount
Sales Tax (11,4
Grand Total
279.34
Deductible
Net Total (500.00)
(220.66)
Estimate Version
Total $
Original 23396
Supplement S01
45.38 Insurance Total $:
0:00-
Received from Insurance $:
0.00 Balance due from Insurance $:
0.00 Customer Total $:
279.34
Received from Customer $:
9.00 Balance due from Customer $:
279.34
See attached itemized estimate for the repairs that have been completed by Service King Collision Repair Centers. All repairs will be based on Service King Collision Repair Centers estimate and invoice and not of any other party. als
Acknowledgement of Notice and Consent
I acknowledge notice and oral approval of an increase in the original estimated price. 2,6,2023
Signature or Initials 3.00
Date
AC spec (if applicable) Windshield Installation*
High side PSI: Date: —
Low side PSI:
Time: - am / pm
Center Vent Temp:
Cure Time: Customer Initials:
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 = Structura
1/27/2023 5:21:30 PM
SK/CRASH #0270 MONTCLAIR Workfile ID: 928c96a7
Federal ID: 75-1781281
CRASHCHAMPIONS To schedule repairs please call 1-866-730-5464 State EPA: CAL000410901 COLLISION SPRAIA TEAM BAR: ARD284082
5534 Arrow Highway, Montclair, CA 91763
Phone: (909) 985-3083
FAX: (909) 931-0065
Final Bill
RO Number: 270003316
Customer: Insurance:
Adjuster: Non-CAT Auto Estimator: Kenneth Ray
MORALES II, MICHAEL GARRISON PROPERTY & Phone:
(000) 800-5318 Create Date: 1/10/2023
x222 Business
Visit us @ USAA.com or Call Claim: 0377794890000000 96a7 04001 1283
SN BERNDNO, CA 92411 San Antonio, TX 78268 Loss Date: 0901 1/9/2023
4002
Deductible: 500.00
2019 ACUR ILX 4D SED 4-2.4L Gasoline Gasoline Direct Injection Platinum White Trico Interior Color: Black Mileage In: 86,892
Vehicle Out: 2/6/2023
License: Exterior Color: Platinum White Trico Mileage Out:
State: CA Production Date: 9/2019 Condition:
Job#: 270003316
Line Ver Operation Description
Qty Extended Part Labor Type • Paint
Price $ Type
E01 CLAIM#037779489000000001001, 3001,
& 4001 PERFORMED TOGETHER
2 E01 **********USAA NOTES***********
3 E01 For Supplements use Estimate Share
within CCC One
E01 Have Questions or Non-CCC User?
E01 Call 800.637.8511 - Press 2 for Repair
Facility
Then Press 2 for Tech Support, Then
Press 4 for "All Other"
16 E01 RADIATOR SUPPORT
E01 Remove/Replace Lower shield 1
44.77T OEM 0.3 Body
S01 Remove/Replace Lower shield fastener
2 1.04T OEM
10 E01 Remove/Replace Lower shield clip 8
4.16T OEM
11 S01 Remove/Replace Lower engine cover 1 38.13T
OEM 0.3 Body
12 S01 Remove/Replace Lower engine cover clip
12 6.00T Other
13 E01 Remove/Replace RT Lower shield 1 7.88T OEM
0.2 Body
14 E01 Remove/Replace Center Lower shield 26.12T
OEM 0.2 Body
S01 Remove/Replace Center lower shield clip 4 15.20T Non OEM 16 E01 Remove/Install LT Lower shield
OEM 0.2 Body
17 S01 Remove/Replace Lower shield screw 4 16.72T OEM
18 S01 Remove/Replace Lower shield nut 4
31.80T OEM
19 S01 Remove/Replace Lower shield clip 2 9.64T OEM
9 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
1/27/2023 5:21:30 PM
3/20/23, 3:42 PM Mail - Guizars insurance - Outlook
Peppe
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opel
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