128231
CITY OF RIALTO CITY CLERKS DATE STATES
LIABILITY 20
OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY AM||: 49
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:
Edward Albert Montoya Jr
FULL NAME DATE OF BIRTH
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 09/26/2023 TIME: 0620 Б A O 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.
On northbound Cactus Ave north of Eucalyptus Ave
3. HOW DID DAMAGE OR INJURY OCCUR?
It was still dark outside. Rialto PD officer had a big rig pulled over to the right hand side with lights on. Moved into the center lane for the safety of the officer. At this point 1 was between the big rig and the center curbed median. At this time I struck something laying in the road. I learned that it was 6' angle iron by going to the PD and spoke with officer. Report submitted.
4. WERE POLICE AT THE SCENE? # YES • NO WERE PARAMEDICS AT THE SCENE? DYES KINO
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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $2440.95 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 09/26/2023 Amount: $ 2440.95
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $2440.95 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 09/26/2023 Amount: $2440.95
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $2440.95
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL (S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
=
TELEPHONE: () TELEPHONE: () 02
DATE: _ TIME: DAM 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 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.
Angle
CURB
Crotus AvE
RPD BIGRIG
OFFICERPARKWAY
7 SIDEWALK
= N
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU (I CERTIFY (OBBECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Edward Albert Montoya Jr 10/31/2023
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 (909)874-4470
CALIBER COLLISION 0003
421 W RIALTO AVE •
RIALTO, CA 92376
10/27/2023
14:43:28
DEBIT CARD
DEBIT SALE
Card #
XXXXXXXXXXXX5191
Network: MAESTRO
Chip Card: Debit
AID:
A0000000042203
SEQ #: 2
Batch # 2023 NOV 16
INVOICE 735
3021472 CITY OF RIALTO
Approval Code: 001461
Entry Method: Chip Read CLER EIVES
Mode:
Issuer - PIN Verified AMI1: 49
SALE AMOUNT $500.00
RESTORING THE RHYTHM OF YOUR LIFE
CUSTOMER COPY
CALIBER CALIBER - RIALTO Workfile ID: 6082a812
Federal ID: 33-0730794
RESTORING THE RHYTHM OF YOUR LIFE State EPA: CAL000265317 421 West Rialto Avenue, RIALTO, CA 92376 BAR: ARD299767 COLLISION Phone: (909) 874-4470
FAX: (909) 874-4561
Final Bill
RO Number: 3021472
Customer: Insurance: Adjuster:
Kristen Patricca Estimator: Frank Cordova
MONTOYA, EDWARD UNITED SERVICES AUTOMOBILE Phone: (800) 531-8722 Create Date: 9/26/2023
Business
Visit us at USAA.com or Call Claim: 0142965520000008
00001
RIALTO, CA 92377 San Antonio, TX 78265 Loss Date: 9/26/2023 Deductible: 500.00
2018 GMC Sierra 1500 Denali Crew Cab 143.5" WB 4WD 4D SHORT 8-6.2L Flex Fuel Direct Injection GRAY VIN: Interior Color: BLACK
Mileage In: 45,113 Vehicle Out: 10/26/2023
License: Exterior Color: GRAY
Mileage Out: 45,150
State: CA Production Date: 8/2018
Condition: Job #:
Line Ver Operation Description Qty Extended
Part Labor $ Type Paint
Price $ Type
1 E01 For Supplements Use Estimate Share
Within CCC One
2 E01 V 16
Have Questions or Non-CCC User?
3 E01 Call 800:637.8511 - Press 2 for Repair
Facility pang OF RIALTO
4 E01 Then Press 2 for Technical Support, AMI: 49
5 E01 Then Press 4 for "All Other"
6 E01 Sublet
DIAGNOSE OIL BURNING SMELL, NO LEAKS & NO BURNINS COL FSUME NOTE: ALSO INSPECTED REAR SUSPENSION, FOUND NOTHING VISUALLY
DAMAGED
7 E01 WHEELS
8 E01 Remove/Replace LT/Rear Wheel, alloy
1 920.54T OEM 6.30 Body
NOTE: USED WHEEL 6-7 BUSINESS DAYS OUT, MEMBER IN A RENTAL,
ORDERING OEM TO EXPEDITE REPAIRS
E01 Remove/Install Spare R&I wheel
10 501 6.30 Body
VEHICLE DIAGNOSTICS
11 S01 Sublet Fuel Surcharge
1 5.00 Other
12 E01 TIRES
13 S01 Remove/Replace BDGST P285/45R22 Dueler HL Alenza 1 452.00T Other
BW 110H
14 501 Sublet Balance Tire and Wheel
1 20.00 Sublet
15 501 Sublet Alignment, 4-wheel
1 90.00 Sublet
16 E01 Repair Pre-Repair diagnostic scan
17 E01 Sublet Pre-Repair diagnostic scan 31,50 Body
1 50.00 Other
Mechanical, Ref = Refinish, Struc = Structura
10/27/2023 11:38:43 AM
Final Bill
RO Number: 3021472
2018 GMC Sierra 1500 Denali Crew Cab 143.5" WB 4WD 4D SHORT 8-6.2L Flex Fuel Direct Injection GRAY 18 E01 Repair Post-Repair diagnostic scan
31.50 Body
19 E01 _Sublet Post-Repair diagnostic scan 70.00 Other
1 20 S01 Sublet Electronic Stability Control Relearn 1 125.00 Sublet NOTE: CALIBRATE SAS SYSTEM
Estimate Totals Discount $ Markup$ Rate $
Parts Total $
113.00 1,485.54
Sublet/Miscellaneous 82.50
Labor, Body 537.50
63.00 75.60
Subtotal
2,093.64
Bottomline Discount
Sales Tax (33.58)
113.29
Grand Total
2,178.35
Deductible
(500.00)
Net Total
1,678.35
Estimate Version Total $
Original 1,940.95
Supplement S01 237.40
Insurance Total$: 1,678.35
Received from Insurance $: 2023 NOY 16 0.00
Balance due from Insurance $: 1,678.35
Customer Total $: 30500.00
Received from Customer $: * 0.00
AMII
Balance due from Customer $: _ 500.00
NOTES
LO
10/24/2023 01:19 PM Per: Edward Montoya, Authorized repairs E01 lines: 1-17, In the amount of: $1,940.95, At this Phone #: (909) 915-9535, Target Date is: 10/26/2023
10/27/2023 10:13 AM Called Edward Montoya, Phone #: (909) 915-9535, Authorized additional repairs lines 1-20 refer to document: S01 In the revised total amount of: $2,178.35, Revised target completion date is: 10/27/2023 "TERMS & CONDITIONS OF REPAIR SERVICES
1.Payment Upon Completion and Authority to Endorse Checks. Customer agrees that he/she is fully responsible & liable for timely payment of all charges for labor, parts, material & accessories, sublet repairs, & any other charges incurred under these Terms & Conditions, and payment in full shall be made prior to the release of the vehicle. To facilitate timely payment, Customer hereby authorizes Caliber & its authorized employees, to act in Customer's place for the purpose of endorsing, on Customer's behalf, all insurance checks made payable to Caliber and Customer, or to Customer, regarding authorized repairs to the vehicle described in this agreement with such limited authorization terminating upon full payment for the repairs of
2.Additional Repairs. Customer may authorize Caliber to conduct additional repairs that are discovered following closer inspection or disassembly orally, in written form, or via electronic messaging & all such additional repairs shall be listed on the final invoice.
Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech - T = Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman = Mechanical, Ref = Refinish, Struc = Structural
10/27/2023 11:38:43 AM
Final Bill
RO Number: 3021472
2018 GMC Sierra 1500 Denali Crew Cab 143.5" WB 4WD 4D SHORT 8-6.2L Flex Fuel Direct Injection GRAY
3.Sublet Repairs, Repäir Location and Authority to Operate Vehicle. Customer acknowledges & authorizes Caliber, including its subcontractors & employees, as Caliber deems appropriate, to: perform portions of the repairs through use of subcontractors) hired by Caliber; conduct repairs at another Caliber facility; and, operate the vehide, including use on public streets, for the purposes of including, but not limited to, inspecting, testing, pick-up, delivery, & facilitating repairs.
4.Damage or Theft. Customer acknowiedges and agrees that Caliber is not responsible for & does not accept any liability for the theft, or damage to, the vehicle, or any personal property left in the vehicle, that is not a direct result of Caliber's gross negligence. Customer acknowledges that said property is not insured or protected to the amount of the actual cash value thereof, or otherwise, against loss related to theft, fire or vandalism while the property remains with Caliber. Customer further acknowledges that all personal property has been removed from the vehicle, and that Caliber, its employees and its subcontractors are not responsible for inspection thereof.
5.Storage Fees & Lien Sale. Customer authorizes & acknowledges that if the vehicle is not picked up within ten (10) days after Caliber has notified the Customer that the repairs are completed, Caliber may charge daily storage fees at rates that are ordinary & customary for the area, but not to exceed $100 per day. In addition to any and all other available legal & equitable remedies, Caliber may, in accordance with applicable state law, begin lien sale proceedings & sell the vehicle by way of a public auction.
6. Partner Referrals, Customer acknowledges that Caliber has partnerships with various vehicle dealerships and that Caliber may on occasion compensate these dealership partners for referring work to Caliber, to the extent permitted by law. Note that Caliber does not pay any referral fees to towing services for delivering vehicles to Caliber for repairs.
7. DISPUTE SETTLEMENT AND ARBITRATION. CUSTOMER & CALIBER ACKNOWLEDGE AND AGREE THAT IN THE EVENT A DISPUTE OR
CONTROVERSY ARISES CONCERNING THIS AGREEMENT OR THE REPAIRS TO THE VEHICLE, CUSTOMER & CALIBER SHALL FIRST ATTEMPT IN
GOOD FAITH TO SETTLE THE DISPUTE BY MEDIATION ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION UNDER ITS CONSUMER OR COMMERCIAL MEDIATION PROCEDURES, AS APPLICABLE. IN THE EVENT THAT THE MATTER IS NOT SETTLED BY MEDIATION AS PROVIDED FOR
IN THIS PARAGRAPH, CUSTOMER & CALIBER AGREE THAT SUCH DISPUTE OR CONTROVERSY SHALL BE RESOLVED BY BINDING ARBITRATION ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION UNDER ITS CONSUMER OR COMMERCIAL ARBITRATION RULES, AS APPLICABLE.
CUSTOMER HEREBY ACKNOWLEDGES THAT A COPY OF SUCH RULES, A GUIDE TO THE APPLICABLE PROCEDURES AND INFORMATION NOTING THE NEAREST AMERICAN ARBITRATION ASSOCIATION LOCATION IS AVAILABLE FOR CUSTOMER'S REVIEW AT www.adr.org/aaa/faces/rules. CUSTOMER MAY ALSO CONTACT THE AMERICAN ARBITRATION ASSOCIATION AT 212-484-4181 or 888-855-9575. JUDGMENT ON THE ARBITRATION AWARD RENDERED BY THE ARBITRATOR MAY BE ENTERED IN ANY COURT HAVING JURISDICTION THEREOF. IF EITHER CUSTOMER OR CALIBER ELECTS TO RESOLVE A CLAIM BY ARBITRATION, THAT CLAIM SHALL BE ARBITRATED ONLY ON AN INDIVIDUAL BASIS. THERE SHALL BE NO RIGHT OR
AUTHORITY FOR ANY CLAIMS TO BE ARBITRATED ON A CLASS ACTION BASIS OR ON BASES INVOLVING CLAIMS BROUGHT IN A PURPORTED
REPRESENTATIVE CAPACITY, WHETHER ON BEHALF OF THE GENERAL PUBLIC, OTHER CALIBER CUSTOMERS OR OTHER PERSONS SIMILARLY SITUATED. NOTWITHSTANDING THE FOREGOING, CALIBER AND CUSTOMER AGREE THAT CLAIMS ARISING UNDER THE MAGNUSON MOSS WARRANTY ACT ("MMWA"), SHALL BE MEDIATED BUT SHALL NOT BE ARBITRATED. IF MEDIATION DOES NOT RESOLVE A CLAIM UNDER THE MMWA, THE CUSTOMER MAY PURSUE THE MMWA CLAIM, AND ONLY THE MMWA CLAIM, IN COURT. ANY CLAIMS NOT UNDER THE MMWA SHALL BE ARBITRATED AS SET FORTH HEREIN. IN THE EVENT THE CUSTOMER DOES BRING AN MMWA CLAIM IN COURT, CUSTOMER AND CALIBER EXPRESSLY WAIVE THEIR RIGHT TO A TRIAL BY JURY AS TO SUCH CLAIM.
8. Limited Warranty. Subject to the obligations and exclusions below, Caliber warrants the repairs against defects in materials and workmanship for the applicable period of time set forth in Section 8(A) During such time, Caliber will repair or replace any parts which prove to be defective by reason of improper workmanship or materials without charge for parts or labor relating thereto, subject to the terms and conditions herein, including, but not limited to Section 8(C) below. All warranty repairs must be performed at one of Caliber's facilities. If the vehicle is outside Caliber's market area, the warranty repairs may be performed at any repair facility nationwide that is approved in advance by Caliber.
A. Warranty Period. Non-Transferability & Non-Assignability. Except as otherwise provided herein, Caliber warrants the repairs and paint only to Customer and for only as long as Customer owns the vehicle, but in no event for less than sixty (60) days. Customer may not expressly or implicitly transfer or assign any rights granted under this limited warranty.
B. Defects in Manufacturer's Parts, Material or Accessories. In certain instances Caliber may use parts, materials or accessories in its repairs that have been procured from third-party manufacturers and/or suppliers. In such instances, Caliber warrants such parts, materials or accessories only to the extent that the third-party manufacturer or supplier's warranties apply to Caliber.
C. Limitations and Exclusions. This limited warranty does not apply to repairs necessitated by any cause beyond the reasonable control of Caliber, including any defects, damage or malfunctions caused by or resulting from unauthorized service or parts, improper or inadequate vehicle maintenance, use for which any parts or accessories were not designed or approved, alterations, accidents, modification of repairs, subsequent repairs performed by a party other than Caliber (except as set forth in this Section 8), abuse, misuse, neglect, or acts of God. Any and all disputes related to this section shall be resolved according to the procedures set forth in Paragraph 7 above.
D. Environmental Damage. This limited warranty does not apply to damage caused by chemicals, tree sap, road salt, sand, rocks, pebbles, hail, Remanufactured, OEM = New Original Equipment Manufacturer, Recar = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech = T= Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR - Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman = Mechanical, Ref - Refinish, Struc = Structural
10/27/2023 11:38:43 AM
Final Bill
RO Number: 3021472
2018 GMC Sierra 1500 Denali Crew Cab 143.5" WB 4WD 4D SHORT 8-6.2L Flex Fuel Direct Injection GRAY windstorms, sun, pollution or other environmental factors or road hazards that may damage cloth, leather, plastic, wood, vinyl, paint, chrome, upholstery and/or convertible tops.
E. Waiver of Right to Return of Replaced Auto Parts. By entering into this agreement Customer waives any right to the return of auto parts replaced by Caliber and Customer agrees that all parts replaced under this limited warranty shall become the property of Caliber, If you do not wish to waive your rights to return of replaced parts, please inform the center manager before you sign this document so that we may make appropriate arrangements.
9. DISCLAIMERS. THE FOREGOING PARAGRAPH 8 IS THE COMPLETE LIMITED WARRANTY FOR CALIBER REPAIRS AND SUPERSEDES ALL OTHER WARRANTIES AND REPRESENTATIONS, WHETHER ORAL OR WRITTEN. EXCEPT AS EXPRESSLY SET FORTH ABOVE, NO OTHER EXPRESS WARRANTIES ARE MADE WITH RESPECT TO CALIBER REPAIRS IN NO EVENT WILL CALIBER BE LIABLE TO THE CUSTOMER OF THE VEHICLE
INDIRECT INCIDENTAL OR CONSEQUENTIAL LOSSES OF A COMMERCIAL NATUREWHATSOEVER, EVEN IF CALIBER HAS BEEN ADVISED OF THE DESCRIBED IN THIS AGREEMENT, FOR ANY COMMERCIAL DAMAGES, EXPENSES, LOST REVENUES, LOST SAVINGS OR ANY OTHER SPECIAL, POSSIBILTTY OF SUCH DAMAGES. TO THE EXTENT THAT ANY PART OF THIS LIMITED WARRANTY IS IN CONFLICT WITH APPLICABLE LAW, CALIBER WILL FOLLOW APPLICABLE LAW.
10. Entire Agreement, Headings, Validity. Customer acknowledges that he/she has not been induced to authorize repairs by any representation or warranty not set forth in this agreement. This is the entire agreement between Caliber & Customer, and supersedes all existing agreements and all other oral or written communication between them concerning its subject matter. This agreement may only be modified in writing, signed by Caliber & Customer, either through mareal or digital signatures.
Customer Signature Date 10127/63
I acknowledge notice and eral approval of amincrease in the original estimated price.
Customer Signature/ Date 10/27/23
POWER OF ATTORNEY
I Do Hereby Appoint Caliber Collision Centers As My Lawful Attorney In Fact To Accept On My Behalf Any And All Checks, Drafts, Or Bills Of Exchange, And To Endorse All Such Instruments, And Place Them In a Negotiable Position For Deposit To The Aforementioned Business' Account For Credit On My Account For Repairs On My Vehicle.
Initial
27-
ELYER 2023 NOV 16 AMII: 49 CITY OF RIALTO
ERK
Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag - Diagnostic, Elec = Electrical, Mech = T= Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintiess Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman = Mechanical, Ref = Refinish, Struc = Structural
10/27/2023 11:38:43 AM
CITY OF RIALTO
2023 NOV 16 AMI|: 49
RECEIVL
CITY CLEAF
2425:4/120