CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 OCT 23 PM12: 25
TO PERSON OR PROPERTY
CILY CLER+
1. Claims for death, injury to person, orto 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:
Maida Barrios
-
FULL NAME DATE OF BIRTH
(888 ) 2637287 Ext 27758
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
P.O BOX 10730 Santa Ana, CA 92711-0730
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: 08/22/2024 TIME: • AM • PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
ACACIA AVE / FOOTHILL BLVD right in front of the Bank of America.
3. HOW DID DAMAGE OR INJURY OCCUR?
THE OFFICER WAS COMING DOWN FOOTHILL FROM THE LEFT OF OUR INSURED, THE OFFICER WAS
LOOKING DOWN AND SUN WAS IN HER EYES AND SHE STRUCK THE DRIVER SIDE REAR DOOR AND QUARTER PANEL OF OUR INSURED'S VEHICLE.
4. WERE POLICE AT THE SCENE? * YES • NO WERE PARAMEDICS AT THE SCENE? IX 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 OFFICE FROM THE RIALTO POLICE HIT OUR VEHICLE.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $10,727.55 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: MEDICAL BILLS Amount: $ 8,052.97
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $. 18,780.52 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $_
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: L TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Arrowhead Radiology NAME: California Emergency Phy ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: (1
DATE: TIME: DATE: TIME: •AM 0 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 comers. f a city/town vehide 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 vehid 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 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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Andrew Ortega 10/21/24
TYPE OR PRINT NAME DATE
Adjustor
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, CÁ 92376 Hi this is Maida Barrios
Recently send me a mailing of my letters
CITY CLERK RECEIVED 2024 OCT 23 PM 12:25 CITY OF RIALTO TO PAY
03570
vituity SCAM FOR MOBILE www.ePayitOnline.com Code ID: VITUBIL1 Access#: 15931835-1-2488 PAYMENT Online
CCOUNTE mation
CEP AMERICA CALIFORNIA Phone (866) 954-4405, International # (209) 252-0601 Tax Id:
ARROWHEAD REGIONAL MED CTR Use the detachable Payment Stub below and Location of Service:
NEWTON, ERNEST, P.A. Mail enclosed retum envelope
Rendering Provider:
Statement Date: 09/30/24 Pay with a picture in seconds! S App Stare
E80 рач Search Papaya Payments in the App Store
Account #:
Patient Amount Due: $340.17 or go to www.ppaya.com/pay
Primary Insurance: ANTHEM BLUE CROSS CAREL Secondary Insurance:
Amount
Date of Charges Payments Adjustments Due
Service Description of Services
08/22/24 99285 EMERGENCY DEPT VISIT HIGH MDM $1,224.00
CARRIER PAYMENT $179.10-
09/23/24 $704.73-
09/23/24 CARRIER ADJUSTMENT $340.17_
Total:
YOUR INSURANCE HAS APPLIED THEIR PAYMENT TOWARD YOUR YEARLY DEDUCTIBLE. THE BALANCE DUE IS YOUR RESPONSIBILITY. THANK YOU.
SU SEGURO MEDICO HA APLICADO EL SALDO DE SU CUENTA A
SU DEDUCTIBLE ANNUAL. EL SALDO RESTANTE ES SU
RESPONSABILIDAD. GRACIAS
If uninsured or with high medical expenses, you may qualify for a discount, payment plan or Medicaid Program; please contact our office for assistance. If you have insurance, you can submit information via our secure portal at www.spayitonline.com or fill out the back of this form and submit it to [email protected]
Contact Us AMOUNT
Si no tiene seguro medico o tiene gastos médicos altos, puede calificar para un descuento, un [email protected] plan de pago o un programa de Medicaid; Por favor de comunicarse con nuestra oficina para DUE or obtoner ayuda. Si tiene seguro medico, puede enviar información a través de nuestro portal seguro www.epayitonline.com o completar el reverso de este formulario y enviarto a $340.17 (800) 498-7157 [email protected]
6 am - 5:30 pm PST
tach and return
epayitonline.com
CEP AMERICA CALIFORNIA Easiest way to view your statement, PO BOX 582863
make payments, set up a payment plan
MODESTO CA 95358-0046 or submit insurance information
vitutty STATEMENT DATE
ACCOUNTE ARCUNT DUE
09/30/24 $340.17
Patient: MAIDA BARRIOS
MAKE CHECK PAYABLE AND REMIT TO.
01570
MAIDA BARRIOS CEP AMERICA CALIFORNIA
PO BOX 582663
MODESTO CA 95358-0046
MULTIPLE WA 'S TO PAY
vituity 015
SCAN FOR MOBILE www.ePayitOnline.com
PAYMENT Online Code ID: VITUBIL1 Access#: 15931835-1-2489 Account Information
CEP AMERICA CALIFORNIA
Phone (866) 954-4405, Intemational # (209) 252-0601
Tax Id:
Location of Service: ARROWHEAD REGIONAL MED CTR Use the detachable Payment Stub below and Rendering Provider: JOHNSON, STEVEN, D.O. Mail enclosed retum envelope Statement Date: 09/30/24
Pay with a picture in secondsi • Anp Store
Account $: Search Papaya Payments in the App Store
Patient Amount Due: $103.85 or go to www.ppaya.com/pay
Primary Insurance: ANTHEM BLUE CROSS CAREL Secondary insurance:
Date of Amout
Service Description of Services. Charges Payments Adjustments Due 08/27/24 99285 EMERGENCY DEPT VISIT HIGH MDM $1,224.00
09/23/24 CARRIER PAYMENT $415.42-
09/23/24 CARRIER ADJUSTMENT $704.73-
Total: $103.85
YOUR INSURANCE HAS PAID THEIR PORTION OF THE ABOVE CHARGES. THE BALANCE DUE IS YOUR RESPONSIBILITY. THANK YOU
SU SEGURO MEDICO HA PAGADO SU PORCION. EL SALDO TY
RESTANTE ES SU RESPONSABILIDAD. GRACIAS RECEIN CR 2024 OCT 23 PM12:25 CITY OF RIALTO CLERA
If uninsured or with high medical expenses, you may quality for a discount, payment plan or Medicaid Program; please contact our office for assistance. If you have insurance, you can submit information via our secure portal at www.epayitonline.com or fill out the back of this form and submit it to [email protected]
Contact Us AMOUNT
Si no tiene seguro medico o tiene gastos médicos altos, puede calificar para un descuento, un [email protected] plan de pago o un programa de Medicaid; Por favor de comunicarse con nuestra oficina para DUE obtener ayuda. Si tiene seguro medico, puede enviar información a travás de nuestro portal seguro www.spayitonline.com o completar el reverso de esto formulario y enviarlo a $103.85 (800) 498-7157 [email protected]
6 am - 5:30 pm PST
Pleuse detach and retum the baltor portion wuh payment
epayitonline.com
CEP AMERICA CALIFORNIA Easiest way to view your statement, PO BOX 582663
MODESTO CA 95358-0048 make payments, set up a payment plan or submit insurance information
vituity STATEMENT DATE ACCOUKT S
09/30/24 $103.85
Patient: MAIDA BARRIOS
MAKE CHECK PAYABLE AND REMIT TOL
01573
MAIDA BARRIOS CEP AMERICA CALIFORNIA
PO BOX 582663
MODESTO CA 95358-0046
, CalPERS 024452
PO BOX 70000
VAN NUYS, CA 91470-0001 EXPLANATION OF BENEFITS
ISSUE DATE PAGE
September 14, 2024 00001 OF 00003
Subecriber's Mena: MAIDA BARRIOS
Identification Number:
Group Number: DB2501
Group Name: CALPERS PERS GOLD
ACTIVES(PA) RECION3
Product: Medical Plan
32 MAIDA BARRIOS
#013737020101*
Sequence Number: 1306899166 202400274
Patient's Name: MATNA BARRINS Providen of Services: CALIFORNIA EMERGENCY PHYS Claim Number: Place of Service: Outnatient
Claim Processed Date: 09/11/24
Pationt Acct. Number:
Paid Amount: $179.10 To: CALIFORNIA EMERGENCY PHYS
It is your responsibility to pay: 0340.17 It is not your responsibility to pay:
฿704.73
Thank you for using a Network Participating Provider.
SERVICE COINSURANCE
TYPE OF SERVICE TOTAL OTHER PATIENT APPLIED TO COPAYMENT
DATE(S) CLAINS
BILLED AMOUNTS) SAVINGS DEDUCTIBLE
AMOUNT PAYMENT
08/22/24 Emorgency Service 1,224.00 704. 73/01
295,39/02 44. 78/03 179.10
2 TOTAL THIS CLAIM 1,224.00 0.00 704.73 295.39
44.70 179,10
CAEAPS18 COMS
Sequenco Number: 1306899166 202400274
Patient's Name: MAIDA BARRIOS Provider of Services:
Claim Number: 24254FC8955 CALIFORNIA EMERGENCY PHYS
Place of Service: Outpatient
Claim Procossed Date: 09/11/24
Patient Acct. Numbers E8000121586001
Paid Ascunt: 0415.42 To:
CALIFORNIA EMERGENCY PHYS
It is your responsibility to payt $103.85 It is not your responsibility to.pay:
$704.73
Thank you for using a Network Participating Provider.
SERVICE TYPE OF SERVICE TOTAL COINSURANCE
DATE(s) OTHER PATIEN APPLIED TO
BILLED AMOUNTS) COPAYMENT CLAIMS
SAVING: DEDUCTIBLE AMOUNT PAYMENT
08/27/24 Emergency Service 2,224,00
704. 75/01 103, 85/03 415.42
TOTAL THIS CLAIM 1,224,00
0,00 704,73 0,00 103,85
415.42
Member's Medical Deductible Applied to Date:
4 CalPERS PO BOX 70000 024871
VAN NUYS, CA 91470-0001 EXPLANATION OF BENEFITS
ISSUE DATE PAGE
September 7, 2024 00001 OF 00003
Subscriber"s Nane: MAIDA BARRIOS
Identification Munber:
Group Number: DB2501
Group Names CALPERS PERS COLD
ACTIVES (PA) REGION3
*******************ALL FOR AADC 923 Product: Madieel Plan 9643 1 AB 0.593
MAIDA BARRIOS
*013871820101%
Sequence Number: 1023113172 202400028
Patient's Name: MAIDA BARRIAS Provider of Services: RADIOLOGY MEDIC
ARROWHEAD
Claim Number: Place of Service: nutnatiant
Claim Processed Date: 09/04/24 Patient Acct. Number:
Paid Amount: $0.00
It is your responsibility to pay: $204.61 It is not your responsibility to pay: $582.39 Thank you for using a Network Participating Provider.
20240017801 J35C Env (9041) 1 of 5
COINSURANCE
SERVICE TYPE OF SERVICE TOTAL OTHER PATIENT
APPLIED TO COPAYMENT CLAIMS
DATE(s) BILLED AMOUNT (S) SAVINGS DEDUCTIBLE
AMOUNT PAYMENT
08/22/24 Radiology-Extremity 50.00 31, 82/01
18.18/02 0.00
08/22/24 CT Scan-Head/Neck 124.00 88. 48/01 35.52/02
0.00 CAEAP518 COMS 20240900 01387
08/22/24 CT Scan-Head/Neck 124.00 88, 48/01
35,52/02 0,00
08/22/24 Radiology-Spine 31.00 19.20/01
11.80/02 0.00
08/22/24 Radiology - Spine 31.00 19.20/01
11,80/02 0.00
08/22/24 CT Scan-Spine
168.00 116. 92/01 51.08/02
0.00 08/22/24 cT Scan-Spine
168.00 168,00/03
0.00 08/27/24 Radiology-Extrenity
30.00 15.65/01 14.35/02
0,00
08/27/24 Radiology-Extreaity
30.00 15.65/01 14.35/02 0.0D
82130 tzaz
13 AT CITY OF RIALTO
sz:21Wd
026348
CalPERS • BOX 70000 EXPLANATION OF BENEFITS
IAN NUYS, CA 81470-000
PAGE E043502
ISSUE DATE
September 30, 2024 00001 OF 00003
Subsoriber's Name: MAIDA BARRIOS
Identifiention Mumber:
Group Number: DB2501
Group Name: CALPERS PERS GOLD
ACTIVES(PA) REGIONS
*******************ALL FOR AADC 923 Product: Medical Plan 1876 1 AB 0.593
MAIDA BARRIOS
Sequence Number: 1558410217 202400064
Patient's Name: MAIDA BARRIOS Provider of Services: ARROWHEAD REGIONAL MEDICA Claim Number: Place of Service: Nutantiant
Claim Processed Date: 09/27/24 Patient Acct. Number:
Paid Amount: 12,326.38 To: ARROWHEAD REGIONAL MEDICA
It is your responsibility to pay: +6,321.83
COINSURANCE 20241009801 J798
SERVICE TYPE OF SERVICE TOTAL OTHER PATIENT APPLIED TO COPAYNENT CLATHS nATELS) BILLED AMOUNTS) SAVINGS DEDUCTIALE AMOUNT PAYMENT 08/22/24 MEDICAL SERVICES 8,648.21 5.673.22/03 598, 61/01 2,326,38
50.00/02
TOTAL THIS CLAIM 8,648,21 CAEAPSIE COI
5,673.22 0,00 0.00 648,61 2,526.38*
Member's Medical Deductible Applied to Dato: 0500.00
DETATE MESSAGE:
03 doctor/facility charged more
difference between the two amounts.
* If you
an urgent
our website urgent care in your plan's network.
* All services included in
The member is
Sent from Yahoo Mail for iPhone
On Monday, October 7, 2024, 9:57 PM, La Preciosa <[email protected]> wrote:
RIALTO PM 12: 25
LD LERA
CITY Claim Number: CAPA-02410559
2024 OCT Adjuster Name: Andrew Ortega
REPORT OF ACCIDENT
Your name. Maida Barrios was a (please check all that apply) driver passenger • witness vehicle owner property owner other (describe) Accident location include intersecting streets) city and state Foothill Blvd Rialts CA Date and time of Accident_ August 22, 2024 7:20am
Accident Location induding interesting streets): city and state Foothill Bivd/ Acacia Ave Riatto
Weather conditions (check one) Raining Wet Dry Foggy [Snowy Other: sunrise Did the police come to the scene? Yes No Report wilten? Yes No Report#: # 22124-99849 How many vehicles were involved? _
Were any buldings/property damaged (excluding vehicles)? ho
VEHICLE A
Driver_ Maida Barrios Date of Birth
Telephone Number rivers License No.
Address
City, state & zip code Rialto CA 92376
Year 2022Make Toyota Model Camry License Plate No._
Owner of vehicle Maida Barrios
Vehicle Lowed? O Yes No Location of damage rear quarter Panel How many passengers? _ me (Please list name(s) at the bottom of this page.) Were any car seats in the vehicle at the time of the loss? h0 Were any car seats occupied?_ ho If not occupied, were any car seats damaged? _ no
is everyone okay? D Yes No If not, please explain really hurt my left neck, my left arm, left leg and my back.
VEHICLE B
Driver_ Rialto Police Department Dale of Birth
Telephone Number L) Divers License No.
Address
int
City, state & zip code
Year Make Margiven Dote Pato No.-
Owner of vehicle
Vehicle towed? • Yes No Locatoryon damage lf
• Please a net an estam or gris page.)
How many passengers?
Were any car seats in the vehicle at the time of the loss? Were any car seats occupied? If not occupied, were any car seats damaged?
Is everyone okay? El Yes El No, Inot please explain
(I more velicles were involved plause attach an additional sheet) C17-3 112121
Mercury Insurance Corporate Website
Copyright © 2024 Mercury Insurance Services, LLC
888-263-7287 X27758
Claims Specialist
Andrew Ortega
Best regards,
Please fill out and send back to me.
CLAIM NUMBER: CAPA-02410559 / Mercury Insurance Company Your Claim Information
<[email protected]> wrote:
On Tuesday, October 1, 2024, 3:27 PM, [email protected] 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 io fines and confinement in state prison. (CA Insurance Code § 1871.2(a).)
10-7-2024
SIGNATURE DATE
CITY OF RIELTO 2024 OCT 23 PM 12: 25 RECEIVED CITY CLERK
Please list any/all passengers and include addresses & telephone numbers maida Barrios
(Text Only)
Please describe how the accident happened. If possible, draw a diagram at the bottom of this page to help with car. She Said "Sun in her.
How many impacts did you feel, see or hear? _
Who do you feel is at fault and why? Or, what did you think caused this accident? 0001727 00488 02 The police her phone texting
And Sun 10 ber eyes.
What was the purpose of your trip? Going to WORK
Did you have on a Transportation Network application such as Uber or Lyft?_ ho Were you completing a task or running an errand for your employer? No Were you wearing a seatbelt? Yes • No. Were the passengers in your vehicle wearing seatbelts? Witnesses? • Yes No. If yes, please provide us with their names, addresses and telephone numbers Are you related to or acquainted with anyone involved in the accident? • Yes If yes, whom?
Where was the other vehide when vou first saw i? No
Where was the other vehicle when you entered the intersection? Stopped on her phone Why did vou make your left hand tum when you did? It was clear to go Where in the intersection where your vehicles when they collided? - cop
pyK
Andrien
DIAGRAM
MERCURY FIRST-CLASS MAIL
INSURANCE™ PRESORTED
U.S.POSTAGE PAID
ANAHEIM, CA
P.O. Box 10730 Santa Ana, California 92711-0730 CITY OF RIALTO PERMIT NO. 4656 2024 OCT 23 PM12: 36
SEYCLER
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We Appreciate Your Business!
ITCLAP1 52376