MERCURY P.O. Box 10730
Santa Ana, CA 92711-0730
INSURANCE
888-917-6372
July 18, 2023
Rialto City Clerk's Office
150 S. Palm Ave
Rialto, CA 92376
RE: OUR INSURED: MARWAN AWAD
OUR CLAIM NUMBER: CAPA-02109151
DATE OF LOSS: APRIL 18, 2023
City Employee: Adamari Romano
Dear Rialto City Clerk's Office:
Please see the attached Claim For Damages form.
I am the adjuster assigned to the claim for Mercury Insurance. Please contact me at the undersigned to discuss the claim at your earliest convenience.
As mandated by law we are required to inform you of your rights pertaining to protecting your claim.
Any lawsuit seeking recovery of property damages as a result of this accident must be filed within three (3) years of the accident date, or by April 18, 2026. If not timely filed, said actions, will be forever Sincerely,
Mercury Insurance Company
Arieonna Anderson
Claims Department
888-917-6372, ext. 25521
CITY CLERK RECEIVED 2023 JUL 20 PM 12: 30 CITY OF RIALTO C2 12/2021
CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 JUL 20 CITY OF RIALT
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). PM RETURN
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 92376 Address: 290 W. Rialto Ave., Riálto, CA 92376
CLAIMANT INFORMATION:
Thaira Awad
-
FULL NAME DATE OF BIRTH
L
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
P.O Box 10730 Santa Ana, CA 92711 Attn: CAPA-02109151
(888-263-7287 x 25521
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 04/18/2023 3:30 pm 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.
W. Cactus Ave and S. Randall Rialto, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
This accident involved 2 civilian vehicles and 1 patrol unit.
4. WERE POLICE AT THE SCENE? • YES • NO WERE PARAMEDICS AT THE SCENE? DYES • 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.
This accident was caused by a party running the red light. Officer Adamari Romano was involved in this accident.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_47,960.07 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 2021 Toyota Highlander 46,695.33
Amount: $
Item/Date: Towing and Rental Amount: $ 1214.74
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:
TELEPHONE: 1)
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.
S Cactus Ave
2023 JUL 20
A.-1/B-1
CURB CITY CLERK KECEIYEL
B-1/C-1 CITY OF RIALTO
Randall Ar
PM 12:30
SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Arieonna Anderson
SIGNATURE OF CLAIMANT OR AGENT
Arieonna Anderson 07/18/2023
TYPE OR PRINT NAME DATE
Mercury Insurance Claims Adjuster
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
MERCURY
INSURANCE. FIRST-CL
PRESI
U.S.POST
:O. Box 10730 Santa Ana, California 92711-0730 ANAHE
PERMIT
Thank You!
We Appreciate Your Business!
CITY CLERY. RECEIVEL 2023 JUL 20 PM 12: 30 CITY OF RIALTO FTCLAP1 92376