CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 NOV - 2 PM 4: 19
TO PERSON OR PROPERTY
RECEIVEL
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
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
GeNiA windhAm
FULL NAME DATE OF BIRTH
COLtON. CA
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 92324- Apt# 343
)
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: 10-17-23 _TIME: 12:30 TRAM DEM
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.
Ar was h
443. W FOOthill BLVD
3. HOW DID DAMAGE OR INJURY OCCUR?
P-1 WAS dRivinG V-2 in The PARking lOT oF The business TogeT it wunshed.
As he wAs pulline do TO The Vacuum statioNs The Tep oF V-I STRUCK iT, Atten Collidingwith IT, IT CAused All UF TrE Vacuum Pipes To Fall And Lanel on Tup oF windhems Vehice →
4. WERE POLICE AT THE SCENE? RYES NO WERE PARAMEDICS AT THE SCENE? • YES 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 TRuck WAs TO Tall ANd Hit The pip
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2,286.85 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: $_ 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: NA
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: •AM 0 PM DATE:
TIME:
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.
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
PARKWAY
SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
11-2-23.
TYPE OR PRINT NAME
DATE
SeLF
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 Continue: (V2) That was being vanumed by Employees of business CITY CLERK RECEIVED 2023 NOV -2 PM 4: 19 CITY OF RIALTO
STATE OF CALIFORIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC CRASH REPORT Page 1 of 4
CHP 555 Page 1 (Rev. 9-19) OPI 060
SPECIAL CONDITIONS NUMBER HIT & RUN gYTY OF RIALTO
INJURED FELONY JUDICIAL DISTRICT LOCAL REPORT NUMBER
ON-DUTY EMERGENCY VEHICLE Rialto
Fontana Superior Court 932311790
PRIVATE PROPERTY NUMBER MSD2023 WOV-2 PM 4: | SCORTING DISTRICT
KILLED BEAT DAY OF WEEK TOW AWAY
San Bernardino 137 Tuesday
CRASH OCCURRED ON
MO. DAY YEAR TIME (2400) NCIC # OFFICER ID
JOO 445 W FOOTHILL BLVD
CILY CLERA 10/17/2023 1120 3609 02306
MILEPOST INFORMATION GPS COORDINATES
PHOTOGRAPHS BY • NONE
FEET OF LATITUDE LONGITUDE
•AT INTERSECTION WITH STATE HWY REL
SGT BREEN
OR FEET OF
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP VEH. YEAR
MAKE / MODEL / COLOR LICENSE NUMBER STATE
1 CA 2008 GMC V3500 PICKUP WHITE
DRIVER NAME (FIRST, MIDDLE, LAST) On Duty Emergency Vehicle
X ERIK STEVEN VALTIERRA OWNER'S NAME
PEDES- X SAME AS DRIVER
STREET ADDRESS
TRIAN
CITY OF RIALTO
128 N WILLOW AVE OWNER'S ADDRESS
X SAME AS DRIVER
PARKE CITY / STATE / ZIP
128 N WILLOW AVE RIALTO, CA 92376
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER X DRIVER • OTHER
BICY- SEX HAIR EYES HEIGHT
CLIST WEIGHT BIRTH DATE RACE Drivable
M BRN BRN 508 190 H • NONE APPARENT • REFER TO NARRATIVE PRIOR MECHANICAL DEFECTS:
OTHER HOME PHONE BUSINESS PHONE
VEHICLE IDENTIFICATION NUMBER 1GDE5V1958F407723
() . (909) 820-2550 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
SHADE IN DAMAGE AREA
OPER. INSURANCE CARRIER POLICY NUMBER
ATOR • UNK. • NONE X MINOR
11 CITY OF RIALTO • MOD. • MAJOR • ROLL-OVER
DIR OF ON STREET OR HIGHWAY THRU TOTAL SPEED
TRAVEL LANE LANES LIMIT DOT
LANES
SOUTH 445W FOOTHILL BLVD CAL-T
TCPIPSC MC/M
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. | VEH. YEAR
MAKE / MODEL / COLOR LICENSE NUMBER STATE
2 DRIVER NAME (FIRST, MIDDLE, LAST)
OWNER'S NAME • SAME AS DRIVER
PEDES. STREET ADDRESS
TRIAN
OWNER'S ADDRESS • SAME AS DRIVER
PARKED CITY / STATE / ZIP
[VEHICL
DISPOSITION OF VEHICLE ON ORDERS OF: •OFFICER • DRIVER • OTHER BICY- SEX HAIR [EYES HEIGHT WEIGHT RACE
CLIST BIRTH DATE
PRIOR MECHANICAL DEFECTS • NONE APPARENT REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE
VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
SHADE IN DAMAGE AREA
OPER. INSURANCE CARRIER POLICY NUMBER UNK. NONE • MINOR MOD. • MAJOR • ROLL-OVER
DIR OF ON STREET OR HIGHWAY THRU TOTAL SPEED
TRAVEL LANE LANES LANES CA DOT
LIMIT
CAL-T TCP/PSC MC/MX
PARTY DRIVERS LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. İVEH. YEAR MAKE / MODEL / COLOR
LICENSE NUMBER STATE
3 DRIVER NAME (FIRST, MIDDLE, LAST)
OWNER'S NAME • SAME AS DRIVER
TRIAN STREETADDRESS
OWNER'S ADDRESS • SAME AS DRIVER
PARKED CITY / STATE / ZIP
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: •OFFICER • DRIVER • OTHER
BICY- SEX HAIR EYES THEIGHT WEIGHT BIRTH DATE
CLIST RACE
PRIOR MECHANICAL DEFECTS TROL NONE APPARENT • REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE
VEHICLE IDENTIFICATION NUMBER: DENTIAL COPY
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
OPER- INSURANCE CARRIER POLICY NUMBER REPUNK. ' NONE 101421 MAGEAREA ATOR
NOTMODER MANOR PEE ROLLOVER Y RELEAS
DIR OF ON STREET OR HIGHWAY THRU TOTA SPEED THE RIALTO POLICE DEPARTMENT
TRAVEL LANE LANES LANES CA
LIMIT
CAL-T ROPIASCTO: Gacia Windham
PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME BY: M.L. 11.01.23 DATE REVIEWED LAMM, RUSTY 02306 Yes aNo N/A SMITH, DANIEL 02320 10/30/2023
STATE OF GALIFORNA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC CRASH CODING Page 2 of 4
CHP 555 Page 2 (Rev. 3-20) OPI 060
DATE OF CRASH (MO. DAY. YEAR) TIME (2400) NCIC # OFFICER ID NUMBER
10/17/2023 1120 3609
02306 932311790
OWNER'S NAME OWNER'S ADDRESS
PROPERTY DAMAGE
GENIA MARIE WINDHAM
1032 N LILAC AVE APT D32 RIALTO, CA 92376
PERSON NOTIFIED TELEPHONE NUMBER
GENIA MARIE WINDHAM OWNER METHOD OF NOTIFICATION (MARK ALL THAT APPLY) LOG/ INCIDENT NUMBER 9092321445 * IN PERSON PHONE DISPATCH CHP 422
DESCRIPTION OF DAMAGE
DENT TO ROOF OF VEHICLE (LIC PLT MN359DP)
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES
OCCUPANTS CHILD RESTRAINT B - UNKNOWN
A - NONE IN VEHICLE ON VETS-L . - AIR BAG DEPLOYEI
B - UNKNOWN R - IN VEHICLE NOT USED 1 - AIR BAG NOT DEPLOYEL
C - LAP BELT USED S - IN VEHICLE USE UNKNOWN N - OTHER
1 TO 9 - STANDARD D - LAP BELT NOT USED T - IN VEHICLE IMPROPER USE P - NOT REQUIRED E - SMOKING 1 2 3 SEATING POSITION E - SHOULDER HARNESS USED U - NONE IN VEHICLE
EJECTED FROM VEHICLE - EATINO
F - SHOULDER HARNESS NOT USED - CHILDREI
4 5 6 10 - REAR OCC. TRK.. VAN. G - LAP/SHOULDER HARNESS USED STATION WAGON. ETC.* M / C BICYCLE HELMET 0 - NOT EJECTED H- ANIMALS 7 8 9 H - LAP/SHOULDER HARNESS NOT USED DRIVER PASSENGER 1 - FULLY EJECTED I- PERSONAL HYGIENE 10 11- POSITION UNKNOWN - PASSIVE RESTRAINT USED V - NO X - NO 2 - PARTIALLY EJECTEI 3 - UNKNOWN J- READING
K - PASSIVE RESTRAINT NOT USED W- YES Y - YES K-OTHER
0 - OTHER P - NOT REQUIRED
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE
PRIMARY CRASH FACTOR MOVEMENT PRECEDING
LIST NUMBER (#) OF PARTY AT FAU TRAFFIC CONTROL DEVICES 1 2 3 VEHICLE AUTOMATION LEVEL 1 2 3 CRASH
A CONTROLS FUNCTIONING X A SAE LEVEL - 0 A STOPPED
A
B CONTROLS NOT FUNCTIONING* B SAE LEVEL • 1 X B PROCEEDING STRAIGHT 1 B OTHER IMPROPER DRIVING:* C CONTROLS OBSCURED C SAE LEVEL - 2 C RAN OFF ROAD UNSAFE SPEED X D NO CONTROLS PRESENT/FACTOR* D SAE LEVEL - 3 D MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF COLLISION E SAE LEVEL - 4
E MAKING LEFT TURN
D UNKNOWN* A HEAD-ON F SAE LEVEL - 5 F MAKING U TURN
SIDEsWIPE G UNKNOWN G BACKING
REAR END H SLOWING / STOPPING
1 2 3 VEHICLE AUTOMATION ENGAGED
WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE 1 PASSING OTHER VEHICLE
X A CLEAR E HIT OBJECT X A NO AUTOMATION J CHANGING LANES
B CLOUDY OVERTURNED B DRIVER ASSISTANCE K PARKING MANEUVER
C RAINING G VEHICLE PEDESTRIAN C PARTIAL ASSISTANCE L ENTERING TRAFFIC SNOWING H OTHER*: D CONDITIONAL AUTOMATION M OTHER UNSAFE TURNING E FOG/ VISIBILITY .FT MOTOR VEHICLE INVOLVED WITH E HIGH AUTOMATION N XING INTO OPPOSING LANE F OTHER*: (MARK 1 TO 2 ITEMS) F FULL AUTOMATION O PARKED G WIND A NON- COLLISION G UNKNOWN* P MERGING
LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY
A DAYLIGHT C OTHER MOTOR VEHICLE
OTHER ASSOCIATED FACTORS) R OTHER*:
DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS) S LANE SPLITTING
DARK - STREET LIGHTS E PARKED MOTOR VEHICLE VC SECTION VIOLATION CITED SOBRIETY - DRUG PHYSICAL
F TRAIN A
DARK - NO STREET LIGHTS (MARK ALL THAT APPLY)
DARK - STREET LIGHTS NOT G BICYCLE CITED X A HAD NOT BEEN DRINKING FUNCTIONING* H ANIMAL:
B HBD - UNDER INFLUENCE
ROADWAY SURFACE FIXED OBJECT: VACCUMING CITED C HBD - NOT UNDER INFLUENCE •
X C VC SECTION VOLATIONI
XA DRY TUBE D HBD. - IMPAIRMENT UNKNOWN.*
B WET OTHER OBJECT. E UNDER DRUG INFLUENCE
J
C SNOWY - ICY E VISION OBSCUREMENT DRE EXAM CONDUCTED
D SLIPPERY (MUDDY, OILY, ETC.) K ADDITIONAL OBJECTS) STRUCK F INATTENTION*: STIMULANT
PEDESTRIAN'S ACTIONS G STOP & GO TRAFFIC HALLUCINOGEN
ROADWAY CONDITIONS (MARK 1 TO 2 ITEMS)
X A NO PEDESTRIANS INVOLVED H ENTERING / LEAVING RAMP DISSOCIATE ANESTHETICS
A HOLES, DEEP RUTS CROSSING IN CROSSWALK I PREVIOUS CRASH NARCOTIC ANALGESIC B LOOSE MATERIAL ON ROADWAY® B AT INTERSECTION J UNFAMILIAR WITH ROAD
INHALANT
C OBSTRUCTION ON ROADWAY. CANTERSECTION SWALK - NOT K DEFECTIVE VEH. EQUIP. CITED CANNABIS
D CONSTRUCTION-REPAIR ZONE DEPRESSANT
E REDUCED ROADWAY WIDTH D CROSSING - NOT IN CROSSWAL L UNINVOLVED VEHICLE F IMPAIRMENT - PHYSICAL F FLOODED• E INROAD - INCLUDES SHOULDER MOTHER: G IMPAIRMENT NOT KNOWN G OTHER: E NOT IN ROAD X N NONE APPARENT H NOT APPLICABLE X H NO UNUSUAL CONDITIONS G APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE I SLEEPY / FATIGUED• Miscellaneous
1 | 2 SPECIAL INFORMATION
Business name:
A HAZARDOUS MATERIAL
Lilac Car Wash B CELL PHONE HANDHELD IN USE
445 W Foothill Bivd
Rialto, CA 92376 C CELL PHONE HANDSFREE IN USE
Employees albe location were note the collision. CONTROLLX COS CELL PHONE NOT IN USE * "See Attached Sketch" CONFIDENTIAL CECEPHONE USE UNKNOWN
RESTRICTED PC F SCHOO, BUS RELATES
• "See Attached factual diagram" NOT FOR TA 3B PARBIKEWAY FACILTS E
THE RIALTO POLIA SHARED ROADWAS TMENT
B'CLASS I- BIKE PATH
REL TO: Genia Wichissin BIKE LANE •
D CLASS I!! - BIKE ROUTE •
BY: M.L. 11.01.23
E CLASS IV - SEPERATED BIKEWAY
STATE OF CALIFORN:A
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
SKETCH Page 3 of 4
CHP 555 Page 4 (Rev. 4-11) OPI 060
DATE OF COLLISION (MO. DAY. YEAR) TIME (2400) NCIC # OFFICER I.D.
NUMBER
10/17/2023 1120 3609 02306
932311790
ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED V-1
AOI #1
Google Imagery ©2023 Airbus. County of Son Bernardino, Maxar Technologies, US Geological Survey
CONTROLLED COPY
CONFIDENTIAL COPY
RESTRICTED PC 11142-11143
NOT FOR THIRD PARTY RELEASE
THE RIALTO POLICE DEPARTMENT
REL TO: Genia Windham
PREPARED BY ID NUMBER MO DAY YEAR
REVIEWERS NAME/. L. 11.01.23 MO DAY YEAR
LAMM, RUSTY 02306 02306 10/17/2023 SMITH, DANIEL 02320
10/30/2023
STATE OF CALIFORMIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
DATE OF COLLISION (MO. DAY. YEAR) TIME (2400) NCIC # OFFICER ID.
NUMBER
10/17/2023 1120 3609 02306 932311790
Notification:
On 10/17/2023, 1 was assigned to work traffic enforcement in the City of Rialto as 93T2 between 0600 hours and 1600 hours. At approximately 1120 hours, I responded to 445 W Foothill Blvd in reference to an none injury traffic collision. I arrived on scene at approximately 1125 hours.
All times, speeds, and measurements in this investigation are approximate.
Summary:
P-1 was driving V-2 in the parking lot of the business to get it washed. As he was pulling up to pipesto tal and land on the stop or indian vehicle 2) that was Geng dalute acum employees of the business.
Area of Impact:
The area of impact was determined to be on the southern portion of the property.
Additional Information:
It should be noted that the business does not have any low clearance signs.
Cause:
P-1 caused this collision by unsafe speed.
Disposition:
Case to date.
Forward to station file for documentation.
CONTROLLED COPY
CONFIDENTIAL COPY
RESTRICTED PC 11142-11143
NOT FOR THIRD PARTY RELEASE
THE RIALTO POLICE DEPARTMENT
REL TO: Genia Windham
PREPARED BY ID NUMBER MO DAY YEAR | REVIEWERS NAME/.L. 11.01.23 MO DAY YEAR LAMM, RUSTY 02306 02306 10/17/2023 SMITH, DANIEL 02320 10/30/2023
INFINITY INSURANCE COMPANY
Kemper CLAIMS OFFICE
please send supplements to
[email protected] or 877-757-4680
PO BOX 2855
Claim #: 2312385086101
Clinton, IA 52733 Workfile ID:
7b719eda
Estimate of Record
Written By: GUSTAVO TRUJILLO, 10/19/2023 2:57:00 PM
Adjuster: Phillips, Mariah, (800) 353-6737 Business
Insured: GENIA WINDHAM Owner Policy #: 10104285501 Claim #: 2312385086101 Type of Loss: Comprehensive Date of Loss: 10/17/2023 11:30 AM Days to Repair: 3 Point of Impact: 16 Non-Collision Deductible: 1000.00 2023 NOV -2 -г.
Owner (Insured): Inspection Location: Appraiser Information: Repair Facility rr GENIA WINDHAM Royal Collision Center CITY OF RIALTO
[email protected] UNK
18000 foothill bivd (909) 347-9633
Fontana, CA 92335
COLTON, CA 92324 Drive-in
(909) 264-3400 Evening (909) 347-6911 Day
(909) 232-1445 Cellular
VEHICLE
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff VIN: 3VWG57AU0MM013082 Production Date: 01/2021 Interior Color: Titan Black Leatherette
License: Odometer: 51918 Exterior Color: Deep Black Pearl Eff State: CA Condition: Fair
TRANSMISSION Air Conditioning Search/Seek Reclining/Lounge Seats Automatic Transmission Intermittent Wipers Auxiliary Audio Connection Leather Seats POWER Tilt Wheel SAFETY Heated Seats
Power Steering Cruise Control Drivers Side Air Bag WHEELS Power Brakes Rear Defogger Passenger Air Bag Aluminum/Alloy Wheels Power Windows Keyless Entry Anti-Lock Brakes (4) PAINT
Power Locks Message Center 4 Wheel Disc Brakes Clear Coat Paint Power Mirrors Steering Wheel Touch Controls Front Side Impact Air Bags Metallic Paint Heated Mirrors Rear Window Wiper Head/Curtain Air Bags OTHER DECOR Telescopic Wheel Hands Free Device Traction Control Dual Mirrors Backup Camera Blind Spot Detection Stability Control Tinted Glass RADIO ROOF Signal Integrated Mirrors
Console/Storage AM Radio Electric Glass Sunroof California Emissions Overhead Console FM Radio SEATS
CONVENIENCE Stereo Bucket Seats
10/19/2023 2:57:00 PM 146623 | 1.9.03.05260 Page 1
Claim #: 2312385086101
Workfile ID: 7b719eda
Estimate of Record
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff Line Oper Description Part Number Qty Extended Labor Paint Price $
1 ROOF
2 * Rpr Roof panel 5G6817111A
10.0 2.1
3 Add for Clear Coat
0.8 4 LIFT GATE
5 * Rpr Spoiler 5G6827936C
3.0 1.5
6 Overlap Major Non-Adj. Panel
-0.2
7 Add for Clear Coat
0.3 8 Repl Wiper arm cap 5K6955435 1 6.67
9 Repl Lift gate glass Volkswagen 5G6845051BJNVB 1 448.90 2.8 10 REAR BUMPER
11 * Rpr Bumper cover
5GM807417AEGRU 2.0 2.6
Overlap Major Non-Adj. Panel -0.2
13 Add for Clear Coat 0.5
QUARTER PANEL
* Rpr RT Quarter panel 5G4809844
10.0 22
Overlap Major Adj, Panel -0.4
17 Add for Clear Coat
0.4 SUBTOTALS 455.57 27.8 9.6
NOTES
Prior Damage Notes:
no upd
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 455.57
Body Labor 27.8 hrs @ $40.00 /hr 1,112.00
Paint Labor 9.6 hrs @ $ 40.00/hr 384.00
Paint Supplies 9.6 hrs @ $29.00/hr 278.40
Subtotal 2,229.97
Sales Tax $ 733.97 @ 7.7500% 56.88
Total Cost of Repairs 2,286.85
Deductible 1000 000
Total Adjustments 1,000.00
Net Cost of Repairs 1,286.85
10/19/2023 2:57:00 PM 146623 | 1.9.03.05260 Page 2
Claim #: 2312385086101
Workfile ID: 7b719eda
Estimate of Record
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff This is not an authorization to repair. Any authorization should be obtained directly from the vehicle owner. This is not a guarantee of payment. For questions regarding payments, please contact the adjuster listed at the top of the estimate.
All supplements require approval prior to completion of repairs. Please send supplements to [email protected]
In order for the vehicle owner to avoid unnecessary out of pocket expenses, the owner should provide a copy of this estimate to the repair facility prior to authorizing repairs.
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING 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.
THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY
BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:
MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART,
A=APPROXIMATE PRICE. LABOR TYPES: B=BODY LABOR, D=DIAGNOSTIC, E=ELECTRICAL, F=FRAME, G=GLASS, M=MECHANICAL, P=PAINT LABOR, S=STRUCTURAL, T=TAXED MISCELLANEOUS, X=NON TAXED
MISCELLANEOUS. CCC ONE: ADJ=ADJACENT, ALGN=ALIGN,
A/M=AFTERMARKET, BLND=BLEND, CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT,
EST=ESTIMATE, EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED, MISC=MISCELLANEOUS, NAGS=NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ=NON ADJACENT, O/H=OVERHAUL,
OP=OPERATION, NO=LINE NUMBER, QTY=QUANTITY,
RECOND=RECONDITION, REFN=REFINISH, REPL=REPLACE, R&I=REMOVE AND INSTALL, R&R=REMOVE AND REPLACE, RPR=REPAIR, RT=RIGHT, SECT=SECTION, SUBL=SUBLET, LT=LEFT, W/O=WITHOUT, W/_=WITH/_ SYMBOLS: # MANUAL LINE ENTRY, *=OTHER [IE.MOTORS DATABASE INFORMATION WAS CHANGED], **=DATABASE LINE WITH AFTERMARKET, N=NOTES ATTACHED TO LINE. OPT OEM=ORIGINAL EQUIPMENT
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT.
''''CURE TIME'MEANS THE LENGTH OF TIME THAT, PER THE ADHESIVE
MANUFACTURER, THE WINDSHIELD ADHESIVE NEEDS TO CURE UNTIL THE
WINDSHIELD CAN PROPERLY FUNCTION AS A SAFETY DEVICE PURSUANT
TO THE FEDERAL MOTOR VEHICLE SAFETY STANDARDS AND THE
VEHICLE MANUFACTURER'S SPECIFICATIONS.
10/19/2023 2:57:00 PM 146623 | 1.9.03.05260 Page 3
Claim #: 2312385086101
Workfile ID: 7b719eda
Estimate of Record
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless otherwise noted, (a) all items are derived from the Guide ERA9251, CCC Data Date 08/17/2023, and potentially other third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are manufactured by or for the vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts are available at OE/Vehicle dealerships or the specified supplier. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships with discounted pricing. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor data provided by third party sources of data may have been modified or may have come from an alternate data source.
Tilde sign (~) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non OEM, A/M or NAGS. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2023 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Incl. =Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF International Certified Part. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
Ral=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Intelligent Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 10/19/2023 2:57:00 PM 146623 | 1.9.03.05260 Page 4
Claim #: 2312385086101
Workfile ID: 7b719eda
Estimate of Record
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff
THE INSURANCE COMPANY THIS ESTIMATE WAS PREPARED BY OR FOR WARRANTS THAT ANY NON-ORIGINAL
EQUIPMENT MANUFACTURER REPLACEMENT CRASH PART INCLUDED IN YOUR ESTIMATE ARE AT LEAST EQUAL TO
THE ORIGINAL EQUIPMENT MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT, AND PERFORMANCE.
10/19/2023 2:57:00 PM 146623 | 1.9.03.05260 Page 5
Claim#: 2312385086101
Workfile ID: 7b719eda
Estimate of Record
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff
ALTERNATE PARTS USAGE
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff VIN: 3VWG57AU0MM013082 Production Date: 01/2021 Interior Color: Titan Black Leatherette
License: Odometer: 51918 Exterior Color: Deep Black Pearl Eff State: CA Condition: Fair
Alternate Part Type # Of Available Parts #Of Parts Selected Aftermarket 2
Optional OEM
Reconditioned
Recycled
10/19/2023 2:57:00 PM 146623 | 1.9.03.05260 Page 6
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