MERCURY P.O. Box 10730
CITY OF RIALTO Santa Ana, CA 92711-0730
INSURANCE
2023 APR 14 AM!I: 33
RECEIVED
April 12, 2023 CITY CLERK
RIALTO CITY CLERK'S OFFICE
150 S. PALM AVE.
RIALTO, CA 92376
RE: OUR INSURED: SHAN BASS
OUR CLAIM NUMBER: CAPA-02079855
DATE OF LOSS: NOVEMBER 21, 2022
YOUR INSURED:
YOUR FILE NUMBER:
DEAR RIALTO CITY CLERK'S OFFICE:
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 $1,415.93
Deductible $500.00
Supplements
Rental Expense
Out of Pocket Expense
Other
Salvage
VLF, if applicable
Total $1,915.93
Total Amount Due $1.915.93
Other:
Please review for payment.
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 fina settlement" or similar wording, whether on the payment itself or on accompanying correspondence, does not function as a release.
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
Claims Department
888-263-7287
Encl.
C21 04/2021
CITY OF RIALTO CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
2023 APR 14 AMII: 33
CLAIM FOR DAMAGES
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 atter the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be file not later than one (1) year after the occurrence (Gov. Code §91112).
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: 150S. Palm Ave.. Rialto, CA. CA.92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Mercury Insurance Company as subrogee to Shan Bass
-
FULL NAME DATE OF BIRTH
Rialto, CA 92376
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 P.O. Box 10730, Santa Ana, CA 92711
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 11/21/2022 TIME: 7:30 • AM X 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.
Riverside ave. & Baseline, Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
Insured drove over an uneven road causing damage.
4. WERE POLICE AT THE SCENE? •YES •NO WERE PARAMEDICS AT THE SCENE? •YES DINO
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.
uneven road
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,915.93 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Repairs Amount: $1,415.93
Item/Date: Deductible Amount: $ 500.00
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
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:
ADDRESS: ADDRESS:
TELEPHONE: () TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: | )
DATE: TIME: DATE: TIME: DAM IPM
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 vehide was involved, designate by letter "A" location of the City/Town vehicle when you first sawit, and by "Blocation 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 APR 10
CURB
TY CLERK CITY OF RIALTO
PARKWAY
SIDEWALK
33 THAVE READ THE OREGONE CAN AND NO THE CONES HERE AN EAT SO IS ME RU BE EVE A TO EE CEPT AS TOM I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Chris Valencia on bekalf of Mercury Anauance
SIGNATURE OF CLAIMANT OR AGENT
4/12/2023
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
AVALON COLLISION CENTER - FONTANA FINAL
15090 HILTON DR, Fontana, CA 92336
Estimate ID
Office: (909) 452-7578 13283942
Fax: (909) 452-7550 S2
[email protected] Claim Number
EPA: CAL000428739 Bar ID: 055885 Tax ID: 460616137 CAPA-0207985500103 Owner Insured
SHAN BASS SHAN BASS Benjamin Hernandez
[email protected]
Classification
None
Supplemented By
Benjamin Hernandez
[email protected]
Classification
None
MERCURY INSURANCE GROUP
Loss Type Claim Number Policy Number Adjuster
Collision CAPA-0207985500103 040118190114590 Rosalie Ciro (800) 521-9693+21824(Wor
k)
[email protected]
Deductible Reported Date Loss Date Inspection Site
500.00 - Not Waived 03/07/2023 11/21/2022 CARSTARAVALON COLLISI
ON FONTANA
15090 Hilton Dr
Fontana, CA 92336
2020 Honda Accord Sport 4 Door Sedan 2.0L 4 Cyl Gas Injected Turbocharged 10 Speed Auto Trans FWD •
Exterior Color Condition
NH731P (Crystal Black Pearl) Good
Drivable Odometer Production Date Mitchell Service Code Yes 63680 02/2020 912046
Primary Point of Impact Secondary Points) of Impact
Undercarriage (21) Right Front Corner (1), Front (12)
Options
Air Conditioning Alum/Alloy Wheels AM-FM Stereo Anti-Lock Brake Sys. (ABS) Auto Air Condition Automatic Headlights Auxiliary Input Bluetooth Wireless Cloth Seat Cruise Control:
Connectivity
Daytime Running Lights Driver Seat With Power Driver-Front Air Bag Dual A/C Electric Defogger Lumbar Support
Electronic Stability Control First Row Bucket Seat Fog Lights Front Heated Seats HD Radio Heated Mirror Keyless Entry System Leather Steering Wheel Left-Curtain Air Bag Manual Sunroof Committed Or Version Mitchell Cloud Estimating TM Printed On Profile Page 1 of7 4/4/2023 Mitchell Estimating 22.: Copyright 1994-2023 Mitchell International, Inc 4/4/2023 Mercury 10:40 AM DEM APR 23_1 All Rights Reserved 10:40 AM Profile Versio
9.0 •
MP3 Player Passenger-Front Air Bag Power Door Locks Power Driver Seat Power Remote Mirror Power Steering Power Windows Rear Bench Seat Rear Spoiler Rearview Camera Satellite Radio Second Row Side Airbag With Side Airbags Side Blind Zone Alert Smart Key System Head Protection
Steering Wheel Mounted Telematic Systems Theft Deterrent Sys. Tilt Steering Wheel Tire Pressure Monitoring Audio Control System
Traction Control/Electronic Trip Computer
SHAN BASS | 2020 Honda Accord Sport
Parts Profile Parts Profile Version
CA CARS Shop Profile 35.0
LABOR PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax Front Bumper
: 200063 Frt Bumper Cover Remove / Body 1.2# 1.2 Existing Install
2 201114 Frt Bumper Cover Repair Body 4.0*# 2.7 Existing 3 AUTO Frt Bumper Cover Refinish Refinish 2.6C 2.6 Existing Only
4 201156 RErt Bumper Fog Lamp Remove / Body INCr# 0.3 Existing Opening Cover Install
S 201157 L Frt Bumper Fog Lamp Remove / Body INCr# 0.3 Existing Opening Cover Install
6 201154 RErt Bumper Filler Strip Remove / Body INC# 0.3 New 71104-TVA- 1 $58.82 Yes Replace A10
7 201155 L Frt Bumper Filler Strip Remove / Body INC# 0.3 New 71109-TVA- 1 $58.82 Yes Replace A10
51 B 200934 Frt Lwr Bumper Cover Remove / Body 0.3 0.3 Aftermarket HO1228159 1 $32.00° Yes
Replace New
52 9 200201 Frt Lwr Bumper Clip (10@ Remove / Body 0.0 0.0 Aftermarket 91505-TM8- 10 $5.20* Yes $0.52) Replace New 003
51 10 201160 R Frt Bumper Cover Beam • Remove/ Body 0.2# 0.2 Aftermarket HO1043132C 1 $43.00* Yes Replace Certified
51 11 201161 L Frt Bumper Cover Beam Remove/ Body 0.2# 0.2 Aftermarket HO1042132C 1 $43.00* Yes Replace Certified
Grille
12 AUTO Grille Assy Overhaul Body 2.3# 2.3
S1 13 AUTO Frt Bumper Cover Remove / Body 1.2# 1.2
Install
14 201183 R Grille Moulding Retainer Remove / Body INCr# 0.3 Install
15 201184 L Grille Moulding Retainer Remove / Body INCr# 0.3 Install
16 200169 Upr Grille Cover Remove / Body INCr# 2.3
Install
17 200171 Lwr Grille Remove / Body INCr# 2.3
Install
18 200172 R Lwr Grille Garnish Remove / Body INCr# 0.2
Install
19 200174 L Lwr Grille Garnish Remove / Body INCr# 0.2
Install
Front Lamps
51 20 200010 R Front Combination Remove / Body 0.3# 0.3 Existing Lamp Install
Committed On Version Mitchell Cloud Estimating™M Printed On Profile Page 2 of7 4/4/2023 litchell Estimating 22. 4/4/2023 Mercury
Copyright 1994-2023 Mitchell International, Inc.
10:40 AM EM APR 23 10:40 AM Profite Versior:
All Rights Reserved 9.0
LABOR -- PART —
Line# Description Operation Type Total Units CEG Type Number Qty Total Price Tax 21 201683 R Frt Fog Lamp Remove / Body 0.5# 0.5 Existing Install
22 201684 L Frt Fog Lamp Remove / Body 0,5₽ 0.5 Existing Install
Front Fender
S1 23 200233 Render Panel Repair Body 1.5*# 1.4 Existing 51 24 AUTO RFender Outside Refinish Refinish 2.0C 2.0 Existing Only
Additional Costs & Materials
25 AUTO Paint/Materials Additional $224.00* Yes
Cost
•
Additional Operations
26 AUTO Clear Coat Additional Refinish 1.4 0.0 $0.00
Operation
Special / Manual Entry
27 900500 Tint Color Additional Body* 0.5 0.0 Existing
Labor
28 900500 Finish Sand & Polish (.5 Additional Body* 0.5° 0.0 Existing Per Panel) Labor
51 29 900500 Recondition Wheel Remove / Body* 0.00 0.0 Remanufacture 1 $209.00* Replace
51 30 900510 Line Markup 20.0% $41.80
31 900501 rt front wheel
32 900500 Mount and Balance Tire Remove / Body* 0.0° 0.0 Sublet 1 $15,00° Replace
33 900510 Line Markup 20.0% $3.00
34 900500 4 Wheel Align Additional Mechanical* 0.0° 0.0 Sublet 1 $100.00* Labor
35 900500 Pre Repair Scan Additional Mechanical* 0.5° 0.0 Existing Labor
36 900500 Post Repair Scan Additional Mechanical* 0.5* 0.0 Existing Labor
37 900500 Basecoat Reduction Refinish Refinish* -0.2° 0.0 Existing Bumper Only
52 38 900500 Pascoat Reduction Refinish Refinish* -0.2" 0.0 Existing Only
39 900501 rt fender
* Judgment Item CIncluded in Clear Coat Calculation
T Included in Two Tone Calculation A Included in Clear Coat and Two Tone Calculation # Labor Note Applies r CEG R&R Time Used for this Labor Operation d Discontinued by Manufacturer [ ] Verify the part number and price before ordering New OEM
OE Discount OE Discount
Aftermarket New Aftermarket New
Aftermarket Certified Aftermarket Certified
Remanufactured Remanufactured
Qual Recycled Part Qual Recycled Part
Sublet Sublet
Recored Recored
Rechromed Rechromed
Existing Existing
Parts Vendors
Committed On Version Printed On Profile Page 3 of7
4/4/2023 Mitchell Estimating 22.5 Mitchell Cloud Estimating™ Copyright 1994-2023 Mitchell International, Inc. 4/4/2023 Mercury 10:40 AM OEM APR 23 V 10:40 AM Profile Versior
All Rights Reserved 9.0
KEYSTONE MERC KEYSIQ KEYSTONE-INS QUALITY PRT
15895 VALLEY BLVD. #100 15895 VALLEY BLVD. #100
FONTANA CA 91761 FONTANA CA 91761
(800) 421-7866 (Work) (800) 421-7866 (Work)
(909) 986-4586 (Work) (909) 986-4586 (Work)
Line Total Line Total
Part # Part #
Price Price
10 HO1043132C $43.00 8 HO1228159 $32.00
11 HO1042132C $43.00
Disclaimer: This estimate has been prepared based on the use of crash parts supplied byasource 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.
Estimate Totals
Labor Units Rate Sublet Add'l Amount Totals
Body Labor 13.2 $52.00 $686.40
Refinish Labor 5.6 $52.00 $291.20
Mechanical Labor 1.0 $75.00 $100.00 $175.00
Total Labor 19.8 $100.00 $1,152.60
Taxable $0.00
Tax 0.0000% $0.00
Non-Taxable $1,152.60
Labor Total $1,152.60
Parts Amount
Taxable Parts $240.84 $240.84
Parts Adjustments' $38.92
Tax 7.7500% $18.21
Non-Taxable $224.00
Parts Total $521.97
Costs Amount
Other Additional Costs $0.00 $0.00
Paint Materials $224.00 $224.00
Taxable $224.00
Paint Materials Rate: $40.00 Tax 7.7500% $17.36
Rate Max: 99.9 units Non-Taxable $0.00
Additional Rate: $650.00 Costs Total $241.36
Gross Totals Amount
Gross Total $1,915.93 $1,915.93
Taxable $458.96
Tax $35.57
Non-Taxable $1,421.40
Gross Total $1,915.93
Adjustments Amount
Deductible -$500.00 -$500.00
Total Customer -$500.00
Responsibility
Committed Or Version Printed On Proffle
4/4/2023 Mitchell Estimating 22.5 Mitchell Cloud Estimating T • Page 4 of7 Copyright 1994-2023 Mitchell International, Inc. 4/4/2023 Mercury 10:40 AM OEM APR 23_V All Rights Reserved 10:40 AM Profile Versior 90 • •
Estimate Totals
Net Estimate Total • $1,415.93
Less Original Net Total $833.21
Net Supplement Amount $582.72
S1: Benjamin Hernandez $600.66
S2: Benjamin Hernandez' -$17.94
Disclaimer: For your protection California law requires the following statement to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Cycle Time Information Estimate Event Log
Due in 3/22/2023 Job Created 3/16/2023 09:40 AM
Supplement 2 Started 3/23/2023 05:19 PM
Arrived At Shop 3/22/2023 Supplement 2 Printed 4/4/2023 10:40 AM Ready for Delivery 3/31/2023 Supplement 2 Committed
Delivered 3/31/2023 214/2023 10:40 AM
Estimate Version
Committed on Version Mitchell Cloud Estimating TM Printed On Profile 4/4/2023 Mitchell Estimating 22.5 Page 5 of 7
Copyright 1994-2023 Mitchell International, Inc. 4/4/2023 Mercury 10:40 AM OEM APR 23 V All Rights Reserved 10:40 AM Profile Version
9.0 Date: 4/4/2023 10:40:52 AM
Estimate ID: 13283942
Supplement: 2 - 4/04/2023 10:40:52 AM
Profile ID: Mercury
Supplement Delta Report
Comparison of Estimate 13283942 Supplement 1 and Supplement 2 Damage Assessed By: Benjamin Hernandez
Supplemented By: Benjamin Hernandez
Insured: SHAN BASS
Owner: SHAN BASS
Vehicle: 2020 Honda Accord Sport
Date of Loss: 11/21/2022
Line Labor Line Item Part Dollar Labor CEG
Item Type Operation Description Type/Num Amount Units Unit Changed Entries
519 Body REMOVE/REPLACE Frt Lwr Bumper Clip 10@ Aftermarket New 4.20° 0.00 0.00T
0.42 91505-TM8-003
9 Body REMOVE/REPLACE 0.5Lwr Bumper Clip 10A1505-M-e 5.20°< 0.00 0.00T 91505-TM8-003
S125 ADD'L COST Paint/Materials 232.00* T
25 ADD'L COST Paint/Materials 224.00- T
Added Entries
38 Refinish REFINISH Basecoat Reduction Existing 0.00*
Fender Existing -0.2* 0.00
39 rt fender
Global Changes
No Deductible, Deductible Reduction Credit, Customer Responsibility, Labor Rate, or Part Adjustment changes were made.
Amount
Original
Estimate 833.21
Supplement 600.66
1 Committed On Version Mitchell Cloud Estimating™ Printed On Profile Page 6 of7 4/4/2023 tchell Estimating 2 4/4/2023 Mercury
10:40 AM MAPR_23 Copyright 299-2 igniReserveternational, Ine. 10:40 AM Profile Versia
9.0 •
Supplement -17.94
Supp 1 36.11
Total Tax
Supp 2 35.57
Total Tax
Net
Supplement 582.72
Amount
Net Total 1,415.93
Program Cal Data Versions
Version
Supp 1 35 APR_23_V
Supp 2 35 APR_23_V
Software
22.5 Copyright (C) 1994 - 2023 Mitchell International
Version:
All Rights Reserved
Committed On Version Printed On Profile • Paze 7 of7
Mitchell Cloud Estimating ™
4/4/2023 Mitchell Estimating 22.5 4/4/2023 Mercury
10:40 AM OEM APR_23_V Copyright 1994-2023 Mitchell International, Inc. Profile Version All Rights Reserved 10:40 AM
9,0
Financials (Total Incurred: $1,415.93): Summary
Scheduled Send D Check Number ÷
• Issue Date = Payment Channel Payment Method Check Type: Pay To $ Amount = Status :
CARSTAR AVALON COLLISION
04/04/2023 04/04/2023 8730432448 Digital Vendor Direct Deposit Indemnity FONTANA $1.415.93 Cleared Claim: CAPA-0207985500103 01 SHAN BASS
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Claim: CAPA-0207985500103 01 SHAN BASS
20230322_161643488_iOS.jpg 20230322_161715568_iOS.jpg
20230322_161724698_iOS.jpg 20230322_161726759_iOS.jpg
Claim: CAPA-0207985500103 01 SHAN BASS
20230322_161733839_iOS.jpg 20230322_161735587_iOS.jpg
20230322_161737032_iOS.jpg 20230322_ 161743636_iOS.jpg
Claim: CAPA-0207985500103 01 SHAN BASS
(8RHE842
20230322_161802062_iOS.jpg 20230322_161810703_iOS.jpg
20230322_161813008_iOS.jpg 20230322L61830285_iOS.jpg
Claim: CAPA-0207985500103 01 SHAN BASS
20230322_161831718_iOS.jpg 20230322_161838182_iOS.jpg
20230322_161839552. _ios.jpg 20230322_161841852_iOS.jpg Claim: CAPA-0207985500103 01 SHAN BASS
12120 not 8!
CABLE
MORIES R HE SP
100 >
120
FDBY HONDA OF AMERICA FG INC AURS CARE
AT MOM
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Claim: CAPA-0207985500103 01 SHAN BASS
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Claim: CAPA-0207985500103 01 SHAN BASS
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20230322_161956854_iOS.jpg 20230323_184753074_iOS.jpg
Claim: CAPA-0207985500103 01 SHAN BASS
20230323_184754670_iOS.jpg 20230323_184755983, 3_ioS.jpg 20230323_184756637_iOS.jpg 20230323_184802576_iOS.jpg
Claim: CAPA-0207985500103 01 SHAN BASS
20230323_184812541_iOS.jpg 20230323_184814721_iOS.jpg
20230323_184817528_iOS.jpg 20230328_181721986_iOS.jpg
Claim: CAPA-0207985500103 01 SHAN BASS
20230328_181833850_iOS jpg 20230328_181835596_iOS.jpg
-
20230328_181837015_iOS.jpg 20230328_181844678_jOS.jpg
Claim: CAPA-0207985500103 01 SHAN BASS
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20230328_181939518_iOS.jpg
US POSTAGE
INSURANCE - CITY OF RIALTO
ZIP 92821 S (
02 411
P.O. BOX 10730 Santa Ana, California 92711-0730 2023 APR 14 ANII: 33 0000383074 AF
ITY CLERI
FIRST CLASS