KEMPER Kemper
P.O. Box 2843
Clinton, IA 52733
USPS CERTIFIED MAIL 62/l200
9414 8149 0289 0187 1209 36
SS 04 000002 76489 F 1 A494
CITY OF RIALTO
150 S Palm Ave
CITY CLERK'S OFFICE
-
Rialto, CA 92376-6406
AN3
CİTY CLER* 2024 APR 23 PM 4: 37 CITY OF RIALTO
Policy underwritten by
KEMPER
Infinity Insurance Company
Named insured: GENIA WINDHAM
Kemper Claim number: 23123850861
P.O. Box 2843
Clinton, IA 52733 Date of loss: October 17, 2023 200000 Date of mailing: April 2, 2024
CITY OF RIALTO
150 S Palm Ave
CITY CLERK'S OFFICE
Rialto, CA 92376-6406
-
Dear CITY OF RIALTO:
Please see attached.
Sincerely,
Madison Taylor
Claims Team
T 800-353-6737, ext. 1351680
F 888-976-2123
[email protected]
-
CITY CLER* RECEIVLU 2024 APR 23 PM 4: 38 CITY OF RIALTO
CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY 6Z/E 200000
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY
1. Claims for death, ijury to parson, ar to personal property must be filed not latar than six (5) months afar the accurence (Gav. Cods §911.2).
2. Claims for damages to real property must be fled not later than pre (1) year after the occurrence (Gov. Code §811.2). RETURN TO:
3.READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clark's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ava., Riako, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Genia Windham N/A
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/A
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Infinity Insurance a/s/o Genia Windham NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM P.O. Box 2843 Clinton, IA 52733 (if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: Tuesday, October 17, 2023 TIME: 11:30
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) incafe on diagram on reverse side of this shee!.
Where appropriate, give street namas and addresses, measurements and landmarks.
Car wash parking lot in Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
A Rialto police van struck a pole that held equipment for the car wash. The pole fell and struck Kemper's insured vehicle that was parked and unoccupied.
4. WERE POLICE AT THE SCENE? 5 YES • 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.
R. Lamm - 02306
2024 APR 23 PM 4: 38 CITY OF RIALTO
B. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_4,584.03 HOW WAS THE ABOVE AMOUNT COMPUTED? Ba specific, list doctor bils, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Repair Estimate Amount: $ 3,584.03
Deductible Amount: $_ 1,000.00
Item/Date:
C OP Y
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 4,584.03 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $ N/A
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additiona/ pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: ( TELEPHONE: | 1.
-
B.IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: / 1
DATE: TIME: DATE: TIME: • AM 07 PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident calms, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST diractions, Indicate place of accident by "X and by showing house numbers or distances to street comers. accident by "8-1' 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
Madison Taylor 4/02/2024
TYPE OR PRINT NAME DATE 202L APR 23
Infinity Insurance a/s/o Genia Windham
TC
RELATIONSHIP TO CLAIMANT
CITY OF RIALTO
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 PN 4:38
KEMPER
Kemper Services Group, PO Box 2843, Clinton, IA 52733
4/2/2024
Please contact the following speclalist for
Carrier: City of Rialto assistance with the subrogation claim Claim: Madison Taylor
Address: 150 S Palm Ave P: 800.353.6737 xt. 1351680
Rialto CA 92376 E: [email protected]
Adjuster: Claim: 23123850861
Fax/ Email:
In Reply Please Refer To
Kemper Claim Number: 23123850861
Kemper Insured: GENIA WINDHAM
Date of Loss: 10/17/2023
Repair Invoice: $ 3,584.03
Rental:
Towing and Storage:
Deductible: 1,000.00 Not Waived
Total Demand: 4,584.03
Medical pending:
Your Insured: ty of Rato / R. Lamm
Your Claim Number:
We have been notified that you are the liability carrier for the person who is responsible for this accident. The damages paid in the accident are shown above. We have also attached documentation to support our claim.
Since your insured was the proximate cause of this accident, we are hereby requesting reimbursement of the damages.
Please make your check or draft payable to: Kemper Services Group as Subrogee of our insured and mail your payment to:
Kemper Services Group
PO Box 2843, Clinton, IA 52733
The payment should be for the Total Demand amount referenced above. If you have already made settlement with our insured please advise us immediately. If you would like to discussthis claim please feel free to contact me. Payments - for less than the total claim amount will be processed and applied to the total claim amount. Negotiating such a payment will not constitute any form of settlement unless settlement has been agreed upon, in advance.
Sincerely,
Infinity Insurance Company
Madison Taylor 2024 APR 23
Subrogation Specialist CITY CLERA RECEIVE
P: 800.353.6737 xt. 1351680
E: [email protected] PN 4: 38 CITY OF RIALTO
Kemper Services Group
PO Box 2843 Phone 800.353.6737
Clinton, IA 52733 Fax 888-976-2123
INFINITY INSURANCE COMPANY
Kemper CLAIMS OFFICE
please send supplements to
[email protected] or 877-757-4680
PO BOX 2855
Claim #: 2312385085101
Clinton, IA 52733 Workfile ID: 7b719eda
Supplement of Record 2 Summary
Written By: GUSTAVO TRUJILLO, 1/16/2024 11:36:58 AM
Adjuster: Phillips, Marlah, (800) 353-6737 Business
Insured: GENIA WINDHAM Owner Policy #: 10104285501 Claim#: 2312385086101 Type of Loss: Comprehensive Date of Loss: 10/17/2073 11:30 AM Days to Repair: 3 Point of Impact: 16 Non-Collision Deductible: 1000.00
Owner (Insured): Inspection Location: Appralser Information: Repeir Fadilly:
GENEA WINDHAM Royal Collision Center [email protected] Royal Collision Center 18000 foothill bivd (909) 347-9633 18000 Foothill Bivd.
Fontana, CA 92335 Fontana, CA 92335
COLTON. CA 92324 Drive-in (909) 347-6911 Business
(909) 347-6911 Day 201430210 Federal ED
ARD000289136 License Number
[email protected]
VEHICLE
2021 VW Gof TSI Automatic 4D H/B 4-1,4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff VIN: Production Date: 01/2021 Interior Calor: Titan Black Leatherette
License: Odameter: 51918 Exterior Color: Deep Black Pearl Bif State: CA Condition: Falr
TRANSMISSION Air Conditioning Search/Seek Reclining/Lounge Seats Automatic Transmission Intermittent Wipers Auxilary 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 Sbeering Wheel Touch Cantrols Frant 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 Contral Tinted Glass RADIO ROOF Signal Integrated Mirrors
Console/Storage AM Radio Electric Glass Sunroof California Emissions Overhead Console FM Radio SEATS
CONVENIENCE 2024 APR 23 PM 4: 3
Stereo Bucket Seats CITY OF RIALTO
CLERT EIVLE
1/16/2024 11:36:58 AM 146623 | 1.9.03.05260 Page 1
Claim #: 2312385086101
Warkfile ID: 7b719eda
Supplement of Record 2 Summary 62/9 200000
2021 WW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff Line Oper Description Part Number Exbended Labor Paint
Price $
1 ROOF
2 * 501 Rpr Roof panel 5G6817111A 18.0 2.1
Add for Clear Coat 0.8
4 501 R&I : Headliner gray SGMBS7501ALZA4 2.6
5 S01 R&I Sunroof glass 5GM877071 1.0
LIFT GATE
* 501 Rpr Spailer 8.0 15
8 Overlap Major Non-Adj. Panel Đ.2
Add for Clear Coat 0.3
10 * S02 Repl Wiper arm cap 2.02 -
11 * S02 Repl Lift gate glass Volkswagen 491,56 Incl
12 S01 R&l Upper trim 0.2
13 501 REJ RT Side trim 0.2
14 S01 R&I LT Side trim 0.2
15 S01 R&I Lower trim 0.4
16 S01 RAI R&I spoiler 0.6
17 REAR BUMPER
18 * > Rpr Bumper cover 2.0 2.6
19 Overlap Major Non-Adj. Panel 0.2
20 Add for Clear Coat 0,5
21 S01 O/H bumper assy NONE 2.1
22 S01 REI RT Reflector Ind.
23 501 R&I LT Reflector Incl.
24 S01 R8I RT Molding exhaust Ind.
25 S01 RaI LT Malding exhaust Ind.
26 501 R&I Malding center Incl.
27 S01 RBr RT Molding upper Incl.
28 501 R&I LT Malding upper Incl.
29 QUARTER PANEL
30 * 501 Rpr •RT Quarter panel 16.0
31 Overlap Major Ady. Panel
32 Add for Clear Coat
33 SD1 R&I Fuel door
34 501 Bind Fuel door
35 S01 Rar RT Wheelhouse liner
36 WINDSHIELD
37 * S01 Rpr Windshield Volkswagen
NOTE: time is to rope glass
38 PILLARS, ROCKER & FLOOR
39 501 Bind RT Aperture panel 5G4B09835A
40 REAR LAMPS 2024 APR 23 PN 4: 38
CLERK CITY OF RIALTO
1/16/2024 11:36:58 AM 146523 | 1.9.03.05260
C P Y
Claim #: 2312385085101
Workfile ID: 76719eda
Supplement of Record 2 Summary
2021 WW Golf TSt Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pear Eff 41 S01 RaJ kr Tall lamp assy 5GM945096F 0.4
42 S01 R&I High maunt lamp 5G0945087B 0.3
43 # Repl Hazardous waste removal - Major 1 5.00
44 # S01 Repl Cover Car 1 5.00 0.2
45 SD1 Rpr Color tint/color match 0.5
46 SO1 Rpr Finish Sand & Polish 1.0
47 # S01 rough pull 2.0 F
48 # 502 Subt INSTALL BACK GLASS 185,00 X
49 VEHICLE DIAGNOSTICS
50 * S02 Rpr Pre-repair scan m D.5 M
51 * SD2 Rpr Post-repair scan
m 0.5 M
SUBTOTALS 693.58 57.9 11.7
NOTES
Prior Damage Notes:
no upd
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 508.58
Body Labor 54.9 hrs $48.00 /hr 2,635.20
Paint Labor 11,7 hrs $ 48.00/hr 561.50
Mechanical Labor 1.0 hrs @ $ 85.00 /hr 85.00
Frame Labor 2.0 hrs @ $64.00/hr 128.00
Paint Supples 11.7 hrs @ $ 35.00 /hr 409.50
Miscellaneous 185.00
Subtotal 4,512.88
Sales Tax $918.08 @ 7.7500% 71,15
Total Cost of Repairs 4,584.03
Deductible 1,000.00
Total Adjustments 1,000.00
Net Cast of Repairs 3,584.03
*719 A119
1/16/2024 11:36:58 AM 17A17078 146623 | 1.9.03.05260 Page 3 Claim #: 2312385086102
Workfile ID: 76719eda
Supplement of Record 2 Summary
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasaline Direct Injection Deep Black Pearl Eff
CUMULATIVE EFFECTS OF SUPPLEMENTS)
Estimate 2,286.85 GUSTAVO TRUILLO
Supplement 501 2,115.24 GUSTAVO TRIDILLO
Supplement SOZ 181.94 GUSTAVO TRWILLO
Workfile Total: $ 4,584.03
TOTAL ADJUSTMENTS: $ 1,000.00
NET COST OF REPAIRS: $ 3,584.03
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 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 SUBIECT 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. COC ONE: AD] =ADJACENT, ALGN=ALIGN,
A/M=AFTERMARKET, BLND=BLEND, CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT, MTY GLLRA ACCLITEL EST=ESTIMATE, EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, 2024 APR 23 PM 4: 38 CITY OF RIALTO INCL= INCLUDED, MISC=MISCELLANEOUS, NAGS-NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADI=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/_ 1/16/2024 11:35:58 AM 146623 | 1.9.03.05260
Claim #: 2312385086101
Workfile ID: 7b719eda
Supplement of Record 2 Summary 62/9 200000
2021 WW Golf TSi Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff
SUPPLEMENT SUMMARY
Line Oper Description Part Number Extended Labor Paint
Price$
Changed Items
10 Repl Wiper arm cap 5K6955435 6.57
10 502 Repl Wiper arm cap 5K6955435 1 Z.02
11 Repl Lif gate glass Volkswagen 5G6845051BJNVB 448.90 -2.8 11 * S02 Repl Lift gate glass Volkswagen 5684505183V3 1 191,56 Incl.
Added Items
48 SOZ Subl INSTALL BACK GLASS 1 185.00 X
49 VEHICLE DIAGNOSTICS -
50 502 Rpr Prerepair scan m 0.5 M
51 502 Rpr Post-repair scan m 0.5 M
SUBTOTALS 228.01 -1.8 0.0
NOTES
Prior Damage Notes:
no upd
TOTALS SUMMARY 22
Cabegory Rate Cost $
Parts 43.01
Body Labor -2.8 hrs @ $48.00/hr -134.40
Mechanical Labor 1.0 hrs @ $ 85.00/hr 85.00
Miscellaneous 185.00
Subtotal 178.61
Sales Tax $ 43.01 @ 7.7500% 3.33
Total Supplement Amount 181.94
NET COST OF SUPPLEMENT 181.94
CITY GLER* RECEIYEL 2024 APR 23 PH 4: 38 CITY OF RIALTE 1/16/2024 11:36:58 AM 146523 | 1.9.03.05260
COPY
Claim #: 2312385086101
Workfile ID: 7b719eda
Supplement of Record 2 Summary
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Peart 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 0L/09/2024, 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 ta 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 Certfied Part, O/H-Overhaul, Oty-Quantity. Refn- Refinish. Repl-Replace: (:
R&I=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. CITY OF RIALTO
3. г
COC 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 PM 4: 38 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. 1/16/2024 11:35:58 AM 146623 | 1.9.03.05260 Page 7
Claim #: 2312385086101
Workfile ID: 7b719eda
Supplement of Record 2 Summary 621L 200000
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pear Eff 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.
-
-
CITY CLEAN RECEIVEL 202, APR 23 PH 4: 38% CITY OF RIALTO 1/16/2024 11:36:58 AM 146623 | 1.9.03.05260
Claim #: 2312385086101
Workfile ID: 7b719eda
Supplement of Record 2 Summary
2021 VW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff
ALTERNATE PARTS USAGE
2021 WW Golf TSI Automatic 4D H/B 41.4L Turbocharged Gasoline Gasoline Direct Injection Deep Black Pearl Eff VIN: 3VWG57AUOMM013082 Production Date: 01/2021 Interior Color: Titan Black Leatherette
License: mn359dp Odometer: 51918 Exterior Color: Deep Black Pearl Eff State: CA Candition: Fair
Alternate Part Type *OF Available Parts # Of Parts Selected Aftermarket
Optional DEM
Reconditioned ..°
Recyded
CITY GLER! HECEIVEL 2024 APR 23 PM 4: 38 CITY OF RIALTO 1/16/2024 11:36:58 AM 146623 | 1.9.03.05260
Claim #: 2312385085101
Workfile ID: 76719eda 67/8฿
Supplement of Record 2 Summary
200000
2021 WW Golf TSI Automatic 4D H/B 4-1.4L Turbocharged Gasaline Gasoline Direct Injection Deep Black Pearl OFF
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.
-
DITY CLERE RECEIYEL 2024 APR 23 PM 4: 38 CITY OF RIALTO 1/16/2024 11:36:58 AM 146623 | 1.9.03.05260
Volkswagen
San Bernardino
1600 Camine Real San Bernardino, CA 92408
Phone. 909.522 3220
www.wsb.com
SOLD TO SHIPPED TO
ROYAL COLLISION CENTER
18000 B POOTHILL BLVD
FONTANA, CA 92335
909-347-6911
RETURES AFTER 3I DAYS 29% HAMDLING CHARDE ON ALL RETURNS ABBOLUTELY NO RETURNS ARBOLUTELY NO RETURNS ON ELECTICAL PAI
SOLUTELY NO RETURNS ON SPECIAL ORDERS NO RETURH ON ANY PART WITHOLT ORIGINAL UMDAMAGED PACKAGING PORTIVELY NO RETURNE WITHOUT THES DOCUMI DECLAMER OF WARRANTIES: Al werent on the products old nendry afe fase made by the matastrer. The soler, colmagen ser Barerand herey tapres, deceas at martents, aner ped mind, dung any issued warranty l mercialty or finess to a sace dare and Volleager Sen Bearsino reler esumes nor suforas any other senses losesume lord em they in copactor wet the sie of lad caducAly fatulen cardaned han does et pors is pret li
OUR FURCHASE ORDER
13156 Payment Due on Delivery 01/11/24 5007607
SHIP VIA
Deliver 01/10/24 CARLOS ARAUDO
NE AMOUNT
1 5K6955435 : CAP 191D 7.02 4.91 4.91
1 5G6845051BJNVB : REARWINDON - SPORD 491.56 344.09 344.09 Freight Out
3VWG5 7A00MM013082
7024 APR 23 CITY OF
PM 4: RIAL. TO
01/11/24 06:38:14 SERVICES OR EQUIPMENT 349:00
DATE PRINTED
PARTS DEPARTMENT HOURS SHIPPING
C.O.D. CHARGE
7:00 a.m. to 6:00 p.m. Mon - Fri SALES TAX OR TAXI.D. XXXXx0736 -00 8:00 a.m. to 5:00 p.m. Sat DEPOSIT ON CONTRACT
349.00
Thank You! ** Initial Invoice ** A/R: ROYA002
NO RETURN DA FLECTRICAL OR SAFETY ITEMS OR SPECIAL ORDERS Invoice no: 7099
Deposit date:
Direct Quality
Appointment/Date of install:
Auto Glass
1-12-2024
909-251-6568
Sunroof Repair - Power Window Repair - ADAS Calibrations Invoice Ro# 13516
Customer Name: Royal Collision Center _Phone:
Address: City: Zip Code
Year Make Model Cash/CC/Check | VIN
2021VW Golf
Quantity Description Cost Price
1 Back Glass
1 R&I 120
1 Urethane Kit 20
Interior Removal 45
Glass is sold "As-is" please read warranty and inspect before signing. Subtotal:
Tax:
Customer Signature:
Total: @ 185:00
Installer Name: Carlos P Deposit:
Balance:
Warranty for urethane set windshield/ back glass instailations: there will be a ilmited ifetime warranty against manufactures defects, al leaks and water leaks; Warranty is only valid when Direct Quality Auta Gless provides new glass and installation. There will be no warranty if the eustomer refuses to follow safa drive away times, rafuses the clip set ar molding or Gasket, refuses to follow instructions after installation and if there is corrosion or rust in the pinch weld, Direct Quality Auto Glass does not guaranten amy stress cracks aftar 3 days of dew window replacement. New Door glass replacement guarantee is only valid against bubbles and wrinkles. Power window repair/repiacement guarantee is onty vaild for 90 days if the part was provided through Direct Quality Auto Glass, 1 year warranty is only valid though labor, parts will only be guaranteed for 90 deys from the fiest day of installation.
Windshield rock chip repairs have a limited lifetime guarantee from spreading, in case the repair fails to bond, the amount of money spent on the repair will be deducted from a new windshield replacement done by Direct Quailty Auto Glass. There is no guarantee against breakage when repairing any windshield. Windshiaid rock chip repsirs never disappear 100% The purpose of the repair is to stop it from spreading, not to make it disappear. By signing above, i am acknowledging that my glass repair, replacement, power window repak/replacement or headlight restoratfon has been done to my full satisfaction. I undarstand the warrenty as stated on this Invoice. There will be a $30.00 fee for any returned checks or faulty transactions. I will be held respansible for any collection cost or court cost. All deposits are non-refundable for any reason. Direct quality auto glass is not responsible for the following: lost or stolen items, glass that may be left behind in areas that the vacuum may not pick up in elther the customer's shide or driveway or anywhere around the working area. In the event where rv insurance does not dev the totel bill, ! will be responsible to nay the batance in full. 708 W Mill St Unit F, San Bernardino CA 92410 909-251-6568 DirectQualityAutoGlass.com
UTO GLASI
BEETY COUNCI 2024 APR 23 CITY
CITY CLERA RECEIVED OF
PM 4: 38 RIALTO
OP Y
IMG_0001
Clalm Rafarance Id: 2312385086101
File Name: PHOTO3
File Date: 10/19/2023
Label: IMG _0001
Nota: Outamate nara CAN A 01171
2023|ClaimRoprosentativo:Phillips|ShopName:RoyalC
Photo Location: Royal Collision Center
Photo Takan By: GUSTAVO TRUJILLO
Estimate Indicator: E01
CITY CLERK RECEIVEL 2024 APR 23 PM 4: 38 CITY CF RIALTO