(Page 1 of 2)
Interinsurance Exchange of the Automobile Club
PO Box 9023, Coppell, TX 75019
February 25, 2024
INITIAL DEMAND
RIALTO CITY CLERK'S OFFICE
150 S PALM AVE 2024 MAR
RIALTO CA 92376-6406
RE: Insured : Andrew Reynoso STELLA* -5 CITY OF RIALT
Claim Number : 016203091
Date of Loss : 12/06/2023
Type of Loss : Auto
Dear Rialto City Clerk's Office:
The Interinsurance Exchange of the Automobile Club has a claim against you resulting from the loss that has occurred on the above date. The claim consists of:
COLL - Collision $2234.28
TOTAL DUE $2234.28
Enclosed are the necessary documents to support our subrogation claim:
Estimate(s)
Photos
: Proof of payments)
Police report
Claim Form
Payment, aim forwad prompt credit to the claim, please note our Claim Number and Date of Los on your Interinsurance Exchange of the Automobile Club
016203091
Corporate Cashiering, Mail Stop A118,
PO Box 25024
Santa Ana, CA 92799
Should you have any questions or need additional information regarding this matter, do not hesitate to contact the undersigned.
Thank you in advance for your prompt attention to this matter.
Ltr No: SCC0104
Rev. Ed : 08/01/2023
(Page 2 of 2)
February 26, 2024
Claim Number: 016203091
Sincerely,
Heather Skinner
Claims Service Representative 2 - Subro
Phone No: 281-866-6117 x. 281-866-6117
Email Address: [email protected]
Ltr No: SCC0104
Rev. Ed.: 08/01/2023
--
Sensitive Regulated Data 06 Pol: CAA 178902977Form: PAIns: ANDREW REYNOSODoL: 12/06/2023Adj: Monica Beeks (Riverside Claim: 016203091 ER7)Claim: 016203091 Years of Membership: 2 Financials (Total Incurred: $2,234.28): Checks
Check Number Pay To Net Amount Issue Date Scheduled Status Bulk Invoice Send Date
100375243 CALIBER COLLISION $2,234.28 01/19/2024 01/18/2024 Cleared
CENTER - RIALTO
User: Heather Skinner Page 1 Feb 25, 20246:16 PM
(Page 1 of 2)
CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 MAR - 5 AM 8: 53
TO PERSON OR PROPERTY
RECEIVEO
CITY CULAA
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 fled 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:
Andrew Reynoso c/o Interns Exchange of the Auto Club
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
PO Box 25024, Santa Ana, CA 92799 ( 281)866-6117
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: 12/06/2023 TIME: 10:45 • AM 0 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. 1366 S Riverside Ave, parking lot of walmart
3. HOW DID DAMAGE OR INJURY OCCUR?
Our insured was parked and sitting in their vehicle. The police officer's vehicle was parked with the vehicle on as the officer went into the store. Officer's vehicle began to reverse and hit our insured's parked vehicle.
4. WERE POLICE AT THE SCENE? X YES NO WERE PARAMEDICS AT THE SCENE? •YES 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.
City of Rialto police department, Officer D. Martinez
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ $2,234.28 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Amount: $
Item/Date:
Item/Date: Amount: $.
(Page 2 of 2)
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $_$2,234.28 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 (atfach additional pages, if necessary) NAME: _ NAME:
ADDRESS: _ ADDRESS:
TELEPHONE: | 2 TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: |)
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 invoived, 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 vehide 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? 20 ITY OF
C -5
Ci
AM
RIALTO
CURB
PARKWAY
7/t 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.
ICERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Heather Skinner 02/25/2024
TYPE OR PRINT NAME DATE
Subrogation 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, CA92376 (Page of 2)
(Page 2 of 2)
146505
(Page 1 of 6)
LexisNexis® appropriate pror better to the
Police Records Retrieval
RISK SOLUTIONS 800-934-9698
[email protected]
Accurint for Insurance
866-277-8407
[email protected]
For tips on ordering visit:
statetips.lexisnexisrisk.com
PAGE COUNT: 6
CLIENT: 7126
DIVISION: CAA-RIVERSIDE
ADJUSTER: MONICA BEEKS
CLAIM: 016203091
TRANSACTION #: 2386389762
DATE: 2024-02-14 12:23:08.0
DATE OF LOSS: 12/06/2023 TIME OF LOSS: 10:50
STREET: WALMART PARKING LOT ON RIVERSIDE AVE
CITY: RIALTO
COUNTY: SAN BERNARDINO
STATE: CA
INVESTIGATING AGENCY: RIALTO PD
REPORT NUMBER: 932313850
REPORT TYPE: AUTOACCIDENT
PARTY1: ANDREW AARON REYNOSO
PARTY2:
PARTY3:
CAR: CIVIC LX MAKE: HOND YEAR: 2022
TAG:
ADDITIONAL INFO:
NOTE: IV SITTING IN HIS CAR IN THE WALMART PARKING LOT. IV WAS BAC THANK YOU FOR YOUR ORDER!
(Page 2 of 6)
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
RAFFIC COLLIS ON REPOR
› 555 Page 1 (Rev 4.11) OPI 06
SPECIAL CONDITIONS NUMBER HIT & RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER
NJURED FELONY
Rialto Fontana Superior Court 932313850
ON-DUTY EMERGENCY VEHICLE NUMEER HIT & RUN COUNTY REPORTING DISTRICT BEAT DAY OF WEEK TOW AWAY
PRIVATE PROPERTY KILLED MISD
San Bemardino 183 4 Wednesday
COLLISION OCCURRED ON MO DAY YEAR TIME (2400) INCIC* OFFICER iD 1366 $ RIVERSIDE AVE 12/06/2023 1045 3809 01323
MILEPOST INFORMATION GPS COORDINATES PHOTOGRAPHS BY • NONG
FEET LATITUDE LONGITUDE
• AT INTERSECTION WITH STATE HWY REL S. MOONEY
OR FEET OF
DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL /COLOR [LICENSE NUMBER STATE PARTY
2007 FORD CROWN VICTORIA BLACK CA
DRIVER NAME (FIRST, MIDDLE, LAST)
OWNER'S NAME • SAME AS DRIVER
STREET ADDRESS CITY OF RIALTO
ERIN
OWNER'S ADDRESS I SAME AS DRIVER
PARKED CITY / STATE I ZP 150 S PALM AVE RIALTO CA 92376
IVEHCLE
DISPOSITION OF VEHICLE ON ORDERS OF OFFICER DRiVER • OTHER SEX HAIR LEYES (HEIGHT TWEIGHT BIRTH DATE RACE Drivable CLIST
PRIOR MECHANICAL DEFECTS NONE APPARENT I REFER TO NARRATIVE OTHER HOME PHONE TousiNESS PHONE VEHICLE IDENTIFICATION NUMBER 909) 820-2550 VEHICLE TYPE DESCRIBE VEHICLE DANAGE SHADE IN DAMAGE AREA INSURANCE CARRIER POLICY NUMBER • UNK • NONE 8 MINOR
98 48 aimi
THE CITY OF RIALTO • MOD. [ MAJOR [J ROLL-OVER 60.
DIR OF ON STREET OR HIGHWAY SPEED LIMIT DOT
CA
TRAVEL
SOUTH 1366 S RIVERSIDE AVE CAL-T TCPIPSC ИСЛАХ
AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL /COLOR LICENSE NUMBER STATE PARTY| DRIVER'S LICENSE NUMBER STATE CLASS
2022 HONDA CIVIC WHITE CA
DRIVER NAME (FIRST, MIDDLE. LAST)
OWNER'S NAME • SAME AS DRIVER
STREET ADDRESS REYNOSO ANDREW AARON
OWNER'S ADDRE • SAME AS DRIVER
IPARKEO CITY / STATE T ZIP
VEHICL
DISPOSITION OF VEHICLE ON ORDERS OF OFFICER DRIVER OTHER SEX THAIR Drivable
CLIST
PRIOR MECHANCAL DEFECTS * NONE APPARENT • REFER TO NARRATIVE
OTHER HOME PHONE VEHICLE IDENTIFIGATION NUMBER
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGE AREA INSURANCE CARRIER POLICY NUMBER • UNK • NONE
01 o -V
• MOD. • MAJOR • ROLL-OVER
AAA
BiR OF TON STREET OR HIGHWAY I SPEEO LIMIT
CA DOT
TRAVEL
NORTH 1366 S RIVERSIDE AVE CAL•T TCP/PSC MC/AX
DRIVER'S LICENSE NUMBER STATE AIR BAG SAFETY EQUIP VEH. YEAR MAKE / MODEL /COLOR STATE PARTY ¡CLASS LICENSE NUMBER
3 DRIVER NAME (FIRST. MIDDLE, LAST)
OWNER'S NAME - • SAMEAS DRIVER
PEDES STREET ADORESS
• UMINERS AUUME • SAME AS DRIVER
[PARKED CITY / STATE /ZIP
DISPOSITION OF VEHICLE ON ORDERS OF • OFFICER ORIVER OTHER -BICY- SEX TEYES THEIGHT WEIGHT BIRTH DATE -TRACE
HAIR
CLIST
PRIOR MECKANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGE AREA
INSURANCE CARRIER POLICY NUMBER CONTROLLED COPY
DIR OF [ON STREET OR HIGHWAY SPEED LIMIT CA
TRAVEL TRESTRICTED PC 11142-14443
CAL-T
NOT FOR THIRD PARTAERELEASE
DISPATCH NOTIFIED REVIEWER'S NAME
PREPARER'S NAME
Yes • No XI NA [SMITH, DANIEL 02320T HE RIALTO POLICE REARTMENTT MOONEY, SHAUN 01323
==: REL TO : LEXIS NEXIS
BY: N.A. 01.31.2024
(Page 3 of 6)
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL Page 2 of 5
TRAFFIC COLLISION CODING
CHP 555 Page 2 (Rev. 4-11) OP! 060
DATE OF COLLISION (MO. DAY" YEAR) • TIME (2400) NCIC # OFFICER LO NUMBER 1045 3609 01323 932313850
12/06/2023
OWNER'S NAME OWNER'S ADDRESS NOTIFIED
• YES • NO
PROP TRY DANAC
DESCRIPTION OF DAMAGE
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES
B- UNKNOWN A - CELLPHONE HANDHELD
OCCUPANTS SHIP PERCENT
A - NONE IN VEHICLE VEHICLE USED - AIR BAG DEPLOYEI B - CELLPHONE HANDSFREE B - UNKNOWN R - IN VEHICLE NOT USED A - AIR BAG NOT DEPLOYE! C - ELECTRONIC EQUIPMENT
C - LAP BELT USED S - IN VEHICLE USE UNKNOW N- OTHER D - RADIO / CD D - LAP BELT NOT USED T- IN VEHICLE IMPROPER US P. NOT REQUIRED E - SMOKING 1 - DRIVER E - SHOULDER HARNESS USED U - NONE IN VEHICLE EJECTED FROM VEHICL F - EATING 1 23 2 TO 6 - PASSENGERS f - SHOULDER HARNESS NOT USE G - CHILDREN 456 7 - STATION WAGON REA 0 - NOT EJECTED H- ANIMALS
8- REAR OCC. TR OR VA: LAP/SHOULDER HARNESS NOT USE BAGENCYGUSSENGER 1 - FULLY EJECTED I- PERSONAL HYGIENE
LAP/SHOULDER
9 - POSITION UNKNOWN J- PASSIVE RESTRAINT USED V - NO X - NO 2 - PARTIALLY EJECTED J- READING 7 0 - OTHER K - PASSIVE RESTRAINT NOY USE W- YES Y - YES 3 - UNKNOWN K- OTHER
REQUIRED
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR 1 21 MOVEMENT PRECEDING
TRAFFIC CONTROL DEVICES 2 | 3 SPECIAL INFORMATION COLLISION
LIST NUMBER (E) OF PARTY AT FAULT
A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED
A B CONTROLS NOT FUNCTIONING* B CELL PHONE HANDHELD IN USE B PROCEEDING STRAIGHT
OTHER IMPROPER DRIVING CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD
X D NO CONTROLS PRESENT/FACTOR' D CELL PHONE NOT IN USE D MAKING RIGHT TURN
C OTHER THAN DRIVER' TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN
X F MAKING U TURN
D UNKNOWN" A HEAO - ON F 75 FT MOTORTRUCK COMBO
G 32 FT TRAILER COMBO XI G BACKING
SIDESWIPE
H SLOWING/STOPPING
REAR END
BROADSIDE I PASSING OTHER VEHICLE
WEATHER (MARK 1 TO 2 ITEMS) D
X A HIT OBJECT J CHANGING LANES
CLEAR
K PARKING MANEUVER
CLOUDY OVERTURNED
G VEHICLE PEDESTRIAN L ENTERING TRAFFIC
C RAINING M OTHER UNSAFE TURNING
D SNOWING H OTHER*:
N XING INTO OPPOSING LANE
FOG / VISIBILITY
MOTOR VEHICLE INVOLVED WITH X O PARKED
OTHER•
A NON - COLLISION P MERGING
G WIND
TRAVELING WRONG WAY
PEDESTRIAN
LIGHTING _ R OTHER*
IX :A DAYLIGHT OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS) B DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS)
DARK - STREET LIGHTS X TE PARKED MOTOR VEHICLE VC SECTION VIOLATICH CITED
D DARK- NO STREET LIGHTS TRAIN
G BICYCLE VC SECTION VOLATOR CITED
DARK - STREET LIGHTS NOT
FUNCTIONING• ANIMAL SOBRIETY - DRUG
VE SECTION VIOLATION CITED PHYSICAL
ROADWAY SURFACE
XIA DRY FIXED OBUECT
WET A HAD NOT BEEN DRINKING
OTHER OBJECT TE VISION OBSCUREMENT B HBD- UNDER INFLUENCE
SNOWY - ICY
| F INATTENTION: C HED - NOT UNDER INFLUENCE •
SLIPPERY (MUDDY. OILY, ETC. G STOP & GO TRAFFIC D HED. - IMPAIRMENT UNKNOWN.
ROOMY COMMONS HARK 1 TO 3 IS PEDESTRIAN'S ACTIONS H ENTERING / LEAVING RAMP E UNDER DRUG INFLUENCE•
X A NO PEDESTRIANS INVOLVED PREVIOUS COLLISION F IMPAIRMENT - PHYSICAL
A HOLES, DEEP RUTS
LOOSE MATERIAL ON ROADWAY• J UNFAMILIAR WITH ROAD © IMPAIRMENT NOT KNOWN
B CROSSING IN CROSSWALK H NOT APPLICABLE
OBSTRUCTION ON ROADWAY AT INTERSECTION DEFECTIVE VEH. EQUIP XX
K CITED I SLEEPY / FATIGUED'
C CROSSING IN CROSSWALK - NOT
AT INTERSECTION
E REDUCED ROADWAY WDTH_. - L UNINVOLVED VEHICLE
E FLOODED ID CROSSING-NOT IN CROSSWALK
-- M OTHER:
G OTHER• E INROAD - INCLUDES SHOULDER
X IN NO UNUSUAL CONDITIONS IF NOT IN ROAD N NONE APPARENT - İG APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE Miscellaneous
• "See Attached Sketch"
• "See Attached factual diagram"
CONTROLLED COPY
CONFIDENTIAL COPY
RESTRICTED PC 11142-11143
NOT FOR THIRD PARTY RELEASE
THE RIALTO POLICE DEPARTMENT
REE TO LEXIS NEXIS
BY: NA. 01.31.2024
(Page 4 of 6)
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL Page 3 of 5
INJURED / WITNESS / PASSENGER
CHP 555 Page 3 (Rev. 4-11) OPI 060
OFFICER ID (NUMBER
DATE OF COLLISION (MO. DAY. YEAR) | TIME (2400) NCIC $
932313850
12/06/2023 1045 3609
EXTENT OF INJURY (*X" ONE) INJURED WAS ("*" ONE)
INGER AGE SEX
Ne'NESS UNL BICYCLIST OTHER
ONLY FATAL SEVERE COMPANT O
OTHER VISTLE INJURY
INJURY INJURY
2 i P °
30 M
Telephone
NAME /D.O.B./ ADDRESS 9099974002
ANDREW AARON REYNOSO 10/16/1993 / 680 N SPRUCE AVE RIALTO CA 92376 USA TEMS RUN NUMBER [TAKEN TO
(INJUREO ONLY) TRANSPORTEO BY
DESCRIBE INJURIES
• •
•
Telephone
NAME /D.O.B.TADDRESS
/ /
(INJURED ONLY) TRANSPORTED BY TEMS RUN NUMBER (TAKEN TO
DESCRIBE INJURIES
• 10100.10 _ Tophom
NAME / D.O.8./ADDRESS
EMS RUN NUMBER • TAKEN TO
(INJURED ONLY) TRANSPORTED BY
DESCRIBE INJURIES
Telephone
NAME /D.O.B. / ADDRESS
NURE ONLY) TRANSPORTED BY EMS RUN NUMBER TAKEN TO
DESCRIBE INJURIES
3002L1 i_ Telephone
NAME /D.0.8. /ADDRESS
| 1 TEMS RUN NUMBER TAKEN TO
INJUREO ONLY TRANSPORTED BY
DESCRIBE INJURIES
010:0 •
• 0
Telephone
INAME / D.Ö.B./ADDRESS
¡SURED ON TRANSPORTEO OY TEMS RUN NUMBER [TAKEN TO
[DESCRIBE INJURIES CONTROLLED COPY
CONFIDENTIAL COPY
RESTRICTED PC 11142-11143
TREVIEWER NOT FOR THIRD PARTY BELFASE
ID NUMBER MO DAY YEAR
PREPARED BY I SMITH, DANIEL BAL TO POLICE DEBARTMENT
:01323 / 12/06/2023
MOONEY, SHAUN 01323 REL TO : LEXIS NEXIS
BY: N.A. 01.31.2024
(Page 5 of 6)
.. •
SEPAROMEN OF GALIFORNIA HIGHWAY PATROL Page 4 or 5
NARRATIVE/SUPPLEMENTAL
CHP 556 Page 4 (Rev. 4-11) OPI 06C
OFFICER I.D NUMBER
(DATE OF COLLISION (MO. DAY YEAR) TIME (2400)
1045 3609 01323 932313850
12/06/2023 -
NOTIFICATION:
On 12-06-2023 at 1045 hrs, I was assigned to the Traffic Division as a Motor Officer and traffic collision investigator for the City of Rialto.
On the above date and time, I was dispatched to the parking lot of 1366 S Riverside Ave in reference to an on- duty emergency vehicle vs. parked motor vehicle traffic collision.
Due to the fact that this collision occurred on private property, there will be no sketch or AOl listed in this report.
PARTIES / VEHICLES INVOLVED:
V-1 - Ford (ODEV)
V-2 - Honda
Passenger V-2 - Reynoso
SUMMARY:
The below information is information obtained by Officer D. Martinez of how the collision occurred.
Officer D. Martinez had parked V-1 in a parking stall located in the western portion parking lot of 1366 S Riverside Ave and facing N/B (Western portion parking lot). Prior to exiting V-1, Officer D. Martinez placed V-1 in the "park position" however left V-1's engine running with the keys in the ignition.
V-2 was already parked and facing N/B in a parking stall behind V-1 with passenger Reynoso occupying the driver front seat.
Officer D. Martinez then went inside Walmart, (1366 S Riverside Ave) for approximately 15 minutes. As Officer ). Martinez was returning to V-1, she noticed that V-1 began to reverse out of the parkin stall. As V-1 wa eversing, V-1's passenger side rear end area collided into V-2's driver side front end area VEHICLE COLLISION DAMAGE:
V-1 - Minor passenger side rear end. CONTROLLED COPY
CONFIDENTIAL COPY
V-2 - Minor driver side front end. RESTRICTED PC 11142-11143
TREVIEWER NAT FOR THIRD PART AFE ASE
/PREPARED BY (ID NUMBER IMO DAY YEAR
¡smITH, DAkE ALTO POLICE DEBARTMENT
_MOONEY, SHAUN 01323 _ 101323 = = 112062023 REL TO: LEXIS NEXIS -
BY: N.A. 01 31 2024
(Page 6 of 6)
SEATED CAL FORNIA HIGHWAY PATROL
NARRATIVE/SUPPLEMENTAL
CHP 556 Page 4 (Rev. 4-11) OPI 060
DATE OF COLLISION (MO. DAY. YEAR) TIME (2400) INCIC B | OFFICER ID NUMBER 1045 3609 01323 932313850
12/06/2023
DISPOSITION:
Upon confirming with Officer D. Martinez that she did in fact place V-1 in park when she exited and due to the fact that Officer D. Martinez left V-1 unattended for approximately 15 minutes, it was suspected that V-1 may have suffered from a transmission mechanical failure by V-1's gear shift lever not being able to be properly positioned in "park".
Photographs were taken and downloaded into Evidence.com.
Reynoso was provided with a police report number regarding the traffic collision.
RECOMMENDATIONS:
Case to file.
CONTROLLED COPY
CONFIDENTIAL COPY
RESTRICTED PC 11142-11143
REVEWER NOT FOR THIRD PARTY AFLEASE
TID NUMBER MO DAY YEAR
PREPARED BY 12/06/2023 i SMITH, DANNE ORALTO POLICE D58A2TMENT MOONEY, SHAUN 01323 01323
REL TO: LEXIS NEXIS
:-.
BY. N.A. 01.31.2024
(Page 1 of 8)
CALIBER - RIALTO Workfile ID: c0270d4f
Federal ID: 33-0730794
RESTORING THE RHYTHM OF YOUR LIFE State ID: N/A
421 West Rialto Avenue, RIALTO, CA 92376 Federal EPA: N/A Phone: (909) 874-4470 State EPA: CAL000265317
BAR: ARD299767
FAX: (909) 874-4561
Supplement of Record 1 with Summary
RO Number: 3021845
Written By: Jason S Jimenez, 1/12/2024 5:56:17 PM
Adjuster: BEEKS, MONICA, (951) 369-4516 Business
Insured: REYNOSO, ANDREW Policy #: Claim #: 016203091-1-7233 Type of Loss: Collision Date of Loss: 12/6/2023 10:50 AM Days to Repair: 0 Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
REYNOSO, ANDREW CALIBER - RIALTO AUTO CLUB ENTERPRISES
421 West Rialto Avenue AACAR
RIALTO, CA 92376
Repair Facility
(909) 874-4470 Business
VEHICLE
2022 HOND Civic Sedan LX w/Continuously Variable Transmission 4D SED 4-2.0L Gasoline Gasoline Direct Injection WHITE PEARL VIN: Interior Color: BLACK Mileage In: 49,904 Vehicle Out: 1/9/2024 License: Exterior Color: WHITE PEARL Mileage Out: 49,904 State: CA Production Date: 12/2021 Condition: Job #: SR TRANSMISSION Intermittent Wipers FM Radio SEATS
Automatic Transmission Tilt Wheel Stereo Cloth Seats
POWER Cruise Control Search/Seek Bucket Seats
Power Steering Rear Defogger Auxiliary Audio Connection Reelining/Lounge Seats Power Brakes Keyless Entry SAFETY WHEELS
Power Windows Alarm Drivers Side Air Bag Wheel Covers
Power Locks Message Center Passenger Air Bag PAINT
Power Mirrors Steering Wheel Touch Controls Anti-Lock Brakes (4) Metallic Paint DECOR Telescopic Wheel 4 Wheel Disc Brakes Three Stage Paint Dual Mirrors Climate Control Front Side Impact Air Bags Stone Guard Tinted Glass Backup Camera Head/Curtain Air Bags OTHER
Console/Storage Intelligent Cruise Hands Free Device Traction Control CONVENIENCE RADIO Rear Side Impact Air Bags Stability Control Air Conditioning AM Radio Lane Departure Warning Xenon or L.E.D. Headlamps 036535 Page 1
1/12/2024 5:56:17 PM
(Page 2 of 8)
Supplement of Record 1 with Summary
RO Number: 3021845
2022 HOND Civic Sedan LX w/Continuously Variable Transmission 4D SED 4-2.0L Gasoline Gasoline Direct Injection WHITE PEARL Line Oper Description Part Number Qty Extended Labor Paint Price $
1 FRONT BUMPER & GRILLE
2 R&I R&I bumper cover 0.00 Inc. 0.0
3 * Rpr Bumper cover 0.00 4.0 2.6
4 Add for Three Stage 0.00 0.0 1.8
5 # Refn Base Coat Reduction 0.00 0.0 -0.3
6 S01 Repl Lower grille 2.0 liter 71151T21A00 1 64.08 0.3 0.0 7 R&I License bracket 0 0.00 0.2 0.0
8 Repl LT Filler cover w/o fog lamps US, 71191T20A11 1 22.48 0.1 0.0 CAN built
9 R&I RT Filler cover w/o fog lamps US, 0.00 0.1 0.0
CAN built
10 Repl LT Upper support 71290T20A00 1 100.67 Incl. 0.0 11 R&I Upper panel Platinum white 0.00 0.5 0.0
12 * Rpr Upper panel Platinum white 0.00 5.0 1.5
13 Add for Three Stage 0.00 0.0 0.6
14 # Refn Base Coat Reduction 0.00 0.0 -0.2
74142T20A11 28.05 Incl. 0.0
15 S01 Repl Seal to hood 1
71207T20A01 1 30.60 0.1 0.0
16 Repl LT Side trim
0.00 0.1 0.0
R&I RT Side trim
71200T20A01 1 172.20 0.6 0 .0
18 S01 Repl Grille w/o park alert w/o Si
71280T20A01 48.83 0.1 0 .0
19 Repl LT Spacer
Repl LT Upper bracket 71107T20A00 13.20 0.1 0
20 91505TM8003 8 4.16 0.0 0.0
21 S01 Repl Bumper cover clip
91505TM8003 8 4.16 0.0 0 .0
22 S01 Repl Lower grille clip
91505TM8003 8 4.16 0.0 0 .0
23 S01 Repl Air deflector clip
91505TM8003 1 0.52 0.0 .0
24 S01 Repl RT Upper support clip
91505TM8003 0.52 0.0 0.0
25 S01 Repl LT Upper support clip
26 S01 Repl RT Plate clip 91505TM8003 2 1.04 0.0 0.0
27 S01 Repl LT Plate clip 91505TM8003 2 1.04 0.0 0.0
28 S01 Repl Upper support clip 91505TM8003 2 1.04 0.0 0.0 29 FRONT LAMPS
30 R&I LT Headlamp assy LX, EX US, 0 0.00 0.4 0.0
CAN built
31 VEHICLE DIAGNOSTICS
32 # Pre-repair scan 1 40.00 X 0.5 0.0
33 Post-repair scan 1 80.00 X 0.5 0.0
#
Adhesion Promotor 1 Incl. T 0.5 0.0
34 # S01
Flex Additive 1 2.50 T 0.0 0.0
35 #
Color Tint 1 1000X 1.0 0.0
36 #
Block Sand and Fill 1 7.50 X 1.0 0.0
37 #
Rpr D&R Battery 0 0.00 0.2 0.0
38 #
DeNib and Polish 1 0.00 X 0.5 0.0
39 #
Subl Hazardous Waste Disposal 1 20.00 X 0.0 0.0
40 #
1/12/2024 5:56:17 PM 036535 Page 2
(Page 3 of 8)
Supplement of Record 1 with Summary
RO Number: 3021845
2022 HOND Civic Sedan LX w/Continuously Variable Transmission 4D SED 4-2.OL Gasoline Gasoline Direct Injection WHITE PEARL 41 # Cover Car for Overspray 1 0.00 X 0.0 0.0
42 # S01 Subl Fuel Surcharge 1 1.00 X 0.0 0.0
43 # 501 Subl Fuel Surcharge 1 1.00 X 0.0
44 # S01 Subl Fuel Surcharge 1 1.00 X 0.0 0.0
45 ** S01 Non OEM Bumper Fascia [Upper] 1 18.51 0.0 0.0 - Qty: 0.3 (Can(s)) - 3M
Polyolefin adhesion promoter
(spray
46 ** S01 Non OEM Bumper Fascia [Upper] 1 23.54 0.0 0.0 - Qty: 0.3 (Cartridge(s) - 3M EZ
sand multi purpose repair
47 ** S01 Non OEM Bumper Fascia [Front] - 1 23.54 0.0 0.0 Qty: 0.3 (Cartridge(s)) - 3M EZ
sand multi purpose repair
48 ** S01 Non OEM Bumper Fascia [Front] - 1 25.72 0.0 0.0 Qty: 1 (Patches)) - 3M Flexible
bumper patch kit
49 ** S01 Non OEM Bumper Fascia [Front] - 1 18.51 0.0 0.0 Qty: 0.3 (Can(s)) - 3M Polyolefin
adhesion promoter (spray
50 ** S01 Non OEM Bumper Fascia [Upper] 1 25.72 0.0 0.0 - Qty: 1 (Patch(es)) - 3M Flexible
bumper patch kit
SUBTOTALS 795.29 15.8 6.0
ESTIMATE TOTALS
Category Basis Rate Cast s
Parts 632.29
Body Labor 15.8 hrs @ $ 51.00/hr 805.80
Paint Labor 6.0 hrs @ $51.00/hr 306.00
Paint Supplies 6.0 hrs @ $ 43.00/hr 258.00
Miscellaneous 163.00
Subtotal 2,165.09
Sales Tax $ 892.79 @ 7.7500% 69.19
Grand Total 2,234.28
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,234.28
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Supplement of Record 1 with Summary
RO Number: 3021845
2022 HOND Civic Sedan LX w/Continuousty Variable Transmission 4D SED 4-2.0L Gasoline Gasoline Direct Injection WHITE PEARL
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Changed Items
2 R&I R&I bumper cover 0.00 - 1.6 0.0
2 S01 R&I R&I bumper cover 0 0.00 Incl. 0.0
26 # Adhesion Promotor 1 -5.00 T -0.5 0.0
34 # S01 Adhesion Promotor 1 Incl. T 0.5 0.0
Deleted Items
R&I Lower grille 2.0 liter 0.00 -0.3 0.0
15 R&I Seal to hood 0.00 Incl. 0.0
18 R&I R&d grille assy 0.00 -0.3 0.0
Added Items
6 S01 Repl Lower grille 2.0 liter 71151T21A00 1 64.08 0.3 0.0 15 S01 Repl Seal to hood 74142T20A11 28.05 Incl. 0.0
18 S01 Repl Grille w/o park alert w/o Si 71200T20A01 172.20 0.6 0.0 21 S01 Repl Bumper cover clip 91505TM8003 8 4.16 0.0 0.0 22 S01 Repl Lower grille clip 91505TM8003 4.16 0.0 0.0
23 S01 Repl Air deflector clip 91505TM8003 4.16 0.0 0.0 24 S01 Repl RT Upper support clip 91505TM8003 0.52 0.0 0.0 25 S01 Repl LT Upper support clip 91505TM8003 0.52 0.0 0.0 26 S01 Repl RT Plate clip 91505TM8003 1.04 0.0 0.0
27 S01 Repl LT Plate clip 91505TM8003 2 1.04 0.0 0.0
28 S01 Repl Upper support clip 91505TM8003 1.04 0.0 0.0 S01 Subl Fuel Surcharge 1.00 X 0.0 0.0
42 #
# Subl Fuel Surcharge 1.00 X 0.0 0.0
43 S01
1.00 X 0.0 0.0
44 # S01 Subl Fuel Surcharge
45 ** S01 Non OEM Bumper Fascia [Upper] 1 18.51 0.0 0.0 - Qty: 0.3 (Can(s)) - 3M
Polyolefin adhesion promoter
(spray
46 ** S01 Non OEM Bumper Fascia [Upper] 1 23.54 0.0 0.0 - Oty: 0.3 (Cartridge(s)) - 3M EZ
sand multi purpose repair
47 ** S01 Non OEM Bumper Fascia (Front] - 1 23.54 0.0 0.0 Qty: 0.3 (Cartridge(s)) - 3M EZ
sand multi purpose repair
Non OEM Bumper Fascia [Front] - 1 25.72 0.0 0.0
48 ** S01
Qty: 1 (Patch(es)) - 3M Flexible
bumper patch kit
49 ** Non OEM Bumper Fascia [Front] - 1 18.51 0.0 0.0
S01
Qty: 0.3 (Can(s)) - 3M Polyolefin
adhesion promoter (spray
50 Non OEM Bumper Fascia [Upper] 1 25.72 0.0 0.0
** S01
- Qty: 1 (Patch(es)) - 3M Flexible
bumper patch kit
1/12/2024 5:56:17 PM 036535 Page 4
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Supplement of Record 1 with Summary
RO Number: 3021845
2022 HOND Civic Sedan LX w/Continuously Variable Transmission 4D SED 4-2.0L Gasoline Gasoline Direct Injection WHITE PEARL SUBTOTALS 414.51 -1.3 0.0
CHANGES TO ADJUSTMENTS
Deductible $ 1,000.00 to $ 0.00
TOTALS SUMMARY
Category Basis Rate Cost $
Parts 416.51
Body Labor - 1.3 hrs @ $ 51.00/hr -66.30
Miscellaneous -2.00
Subtotal 348.21
Sales Tax $ 411.51 7.7500% 31.89
Total Supplement Amount 380.10
Additional Deductible Amount -1,000.00
Supplement Adjustments -1,000.00
NET COST OF SUPPLEMENT 1,380.10
CUMULATIVE EFFECTS OF SUPPLEMENT(S)
Estimate 1,854.18 Jason S Jimenez
Supplement S01 380.10 Jason S Jimenez
Job Total: $ 2,234.28
INSURANCE PAY: $ 2,234.28
036535 Page 5
1/12/2024 5:56:17 PM
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Supplement of Record 1 with Summary
RO Number: 3021845
2022 HOND Civic Sedan LX w/Continuously Variable Transmission 4D SED 4-2.0L Gasoline Gasoline Direct Injection WHITE PEARL ===== ====================================================== Caliber Collision is the industry leader in quality collision repair. Since day one, our highest purpose has been to get people just like you back on the road as quickly as possible and fully restored to the rhythm of your life. You can be sure we do everything possible to ensure your complete satisfaction including:
•Personalized, high quality service from the largest collision repair company in the U.S. •Consistently ranked among the highest customer satisfaction scores in the industry. •Approved by every major insurance company in the U.S.
•Expedited car rental and towing services to get you back on the road again in no time. •Repair work backed by a written, lifetime warranty honored at every location. 124/7/365 customer service to answer questions and put your mind at ease.
This is a preliminary estimate based on visible damage. There may be additional repairs needed once the vehicle is taken apart by our I-CAR Gold Class technicians to identify any additional damage.
If an insurance company has written an estimate for you, please provide us with a copy. Properly endorsed insurance company checks are welcome as payment for the repair of your vehicle. Caliber Collision gladly accepts all major credit cards, debit cards, cashier's and traveler's checks. See your Caliber Collision center for details on acceptance of personal checks.
Before leaving your vehicle with us, please remove all important personal and valuable items from your vehicle.
Caliber Collision is not responsible for belongings left in your vehicle.
Please let us know how we can be of further assistance, and when we can schedule an appointment for your vehicle to be repaired.
Caliber Collision - Restoring The Rhythm Of Your Life
======================= ========= ============
CUSTOMER HAS BEEN PROVIDED A COPY OF THE ESTIMATE AND THE AAA MEMBER PREFERRED REPAIRS BROCHURE.
036535 Page 6
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Supplement of Record 1 with Summary
RO Number: 3021845
2022 HOND Civic Sedan LX w/Continuously Variable Transmission 4D SED 4-2.0L Gasoline Gasoline Direct Injection WHITE PEARL
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.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE 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.
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Supplement of Record 1 with Summary
RO Number: 3021845
2022 HOND Civic Sedan LX w/Continuously Variable Transmission 4D SED 4-2.0L Gasoline Gasoline Direct Injection WHITE PEARL 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 ARG4418, CCC Data Date 01/02/2024, 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.
R&J=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. 1/12/2024 5:56:17 PM 036535 Page 8
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