Email: [email protected]
Toggle® Please include your claim # on any correspondence A Farmers" Company National Document Center
P.O. Box 268994
Oklahoma City, OK 73126-8994
02/13/2025
City Of Rialto - Attention: City Clerks Office
150 S Palm Avenue 2025 FEB 24
Rialto, CA 92376 CITY OF RIALTO
Our Insured: •Sohnu ELYER
Our Claim #: 099 SUB 7008470706-1 AM11: 23
Due orted. 12/13/2024
City Of Rialto Daniel Smith
Your Claim #:
Deductible Amount: $1,000.00
Total Amount Owed: $6,038.19
Dear City Of Rialto - Attention: City Clerks Office:
Our investigation has established that the above loss was caused by your negligence or someone employed by you. It has been determined that you are responsible for all or part of the material damage, bodily injury, property damage, medical, and/or related expense payments paid on our insured's behalf. The current amount we have paid on our insured's behalf may increase or decrease due to additional bodily injury, property damage, medical and/or other related expense payments. The amount for which we are seeking reimbursement for property damage is $6,038.19.
Our theory of liability is as follows:
You have the right to dispute any or all of our claim. If you do not dispute it within seven (7) days of receiving this letter, Farmers Insurance Exchange will assume that it is valid. Be advised that no partial payment, which is less than the full amount, will be considered in any way an acceptance of benefits, a novation or an accord and satisfaction of this claim without the express written release of our claim executed by an individual who identifies himself/herself as a member of our subrogation department. Therefore, our legal rights to enforce collection on the remaining amount of the claim shall not be waived or estopped due to a partial payment by you.
S60000
If you need additional support for our claim or require further information, please contact me. Please send payment to:
National Document Center
PO Box 268992
Oklahoma City, Ok 73126
860000 Thank you,
Brittany Shine
Litigation Claims Representative
JRPWTK3
21st Century Casualty Company
616-803-7653
CITY CLERK RECEIVED 2025 FEB 24 AMII: 23 CITY OF RIALTO JRPWTK3
CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY
CLAIM FOR DAMAGES OF
TO PERSON OR PROPERTY
RIALTO
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:
21st Century Casualty Company A/S/O Sohnu
FULL NAME DATE OF BIRTH
PO BOX 268992 Oklahoma City, OK 73126
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
PO BOX 268992 Oklahoma City, OK 73126 (616-803-7653
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: 12/13/2024 TIME: 7:30 • 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.
E Baseline Rd & Northside Sycamore Ave, Rialto, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Your officer Daniel Smith attempted to overtake the insured on the left side as they made a left turn.
4. WERE POLICE AT THE SCENE? • 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.
Daniel attempted to overtake the insured.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $6,038.19 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Piease attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Damages paid by 21st Century Amount: $5,038.19 Item/Date: Deductible paid by the insured Amount: $ 1,000.00 JRPWTK3
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $6,038.19 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: Amount: $ cit
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $6,038.19
OF
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) 1? NAME: N/A NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: |).
DATE: TIME: L AM LIPM 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.
CURB
PARKWAY
SIDEWALK
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 TRUE I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. 35 05 000093 4JJRPWTK31 CF0214P1 35[4] 000093
SIGNATURE OF CLAIMANT OR AGENT
Brittany Shine 2/11/2025
TYPE OR PRINT NAME DATE
Insurance Representative
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) JFPWTK3 RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 CITY CLERA RECEIVED 2025 FEB 24 AMII: 23 CITY OF RIALTO Claim Reference Id : 7008470706-1_A4963769
File Name : PHOT017
File Date : 12/20/2024
Label • Left Front
Note : Heat Map
Photo Location
Photo Taken By : Smart Review
Estimate Indicator : E01
CITY RECEIVED 2025 FEB 24 AMII: 24 CITY OF RIALTO
CLLAK
Claim Reference Id : 7008470706-1_A4963769
File Name : PHOTO31
File Date : 12/20/2024
Label : Left Rear
Note Heat Map
Photo Location
Photo Taken By : Smart Review
Estimate Indicator : E01
35 07 000093 4JJRPWTK31 CF0214P1 35(4) 000093
CITY CLIE RECEIVED 2025 FEB 24 AMII: 24 CITY OF RIALTO
Claim Reference Id : 7008470706-1_A4963769
File Name : PHOTO5
File Date : 12/20/2024
Label : Right Front
: Heat Map
Photo Location
Photo Taken By : Smart Review
Estimate Indicator : E01
CITY GLEAK RECEIVED 2025 FEB 24 AMII: 24 CITY OF RIALTO Claim Reference Id : 7008470706-1_A4963769
File Name : PHOTO15
File Date : 12/20/2024
Label : Right Rear
Note :Heat Map
Photo Location
Photo Taken By Smart Review
Estimate Indicator
CALIBER - RIALTO Workfile ID: 2def7e17
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 3 with Summary
CA
RO Number: 3023973
Written By: Eduardo Galvan, 1/13/2025 4:40:27 PM
Insured: SOHNU, NO NAME GIVEN Policy #: Claim #:
Type of Loss: COLL1 - Collision Date of Loss: 12/13/2024 7:30 PM Days to Repair: 15 F< RIALTO Point of Impact: 09 Left T-Bone (Left Side) =
Owner: Inspection Location: Insurance Company:
SOHNU, NO NAME GIVEN CALIBER - RIALTO TOGGLE INSURANCE
1569 La Guardia Circe 421 West Rialto Avenue CNTC
Lincoln, CA 95648-0000 RIALTO, CA 92376 P.O. Box 268994 (510) 461-1454 Cell Repair Facility Oklahoma City, OK 73126-8994 (909) 874-4470 Business (800) 445-7911 Business
VEHICLE
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK VIN: Interior Color: BLACK Mileage In: 37,337 Vehicle Out: 1/8/2025 License: Exterior Color: BLACK Mileage Out: 37,362
State: CA Production Date: 5/2023 Condition: Job #: ALEX TRANSMISSION Air Conditioning AM Radio Xenon or L.E.D. Headlamps Automatic Transmission Intermittent Wipers FM Radia Lane Departure Warning POWER Tilt Wheel Stereo ROOF
Power Steering Cruise Control Search/Seek Electric Glass Sunroof Power Brakes Rear Defogger Auxiliary Audio Connection SEATS Power Windows Keyless Entry SAFETY Cloth Seats
Power Locks Alarm Drivers Side Air Bag Bucket Seats
Power Mirrors Message Center Passenger Air Bag Reclining/Lounge Seats Heated Mirrors Steering Wheel Touch Controls Anti-Lock Brakes (4) Heated Seats Power Driver Seat Rear Window Wiper 4 Wheel Disc Brakes WHEELS DECOR Telescopic Wheel Traction Control Aluminum/Alloy Wheels Dual Mirrors Climate Control Stability Control PAINT
35 (4) 000093 Backup Camera Front Side Impact Air Bags Clear Coat Paint Privacy Glass
Console/Storage Remote Starter Head/Curtain Air Bags OTHER Overhead Console Intelligent Cruise Rear Side Impact Air Bags Rear Spoiler CONVENIENCE RADIO Hands Free Device Signal Integrated Mirrors 35 10 000093 4JJRPWTK31 CF0214P1
'13/2025 4:40:27 PM 036535 Page 1
Supplement of Record 3 with Summary
-O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.OL Hybrid Gasoline Direct Injection BLACK Line Oper Description Part Number Qty Extended Labor Paint Price $
1 INFORMATION LABELS
CITY
2 Rpl information labels
Repl Caution label battery temperature 1K90058GA00 1 5.92 of 4 Repl Tire info label w/hybrid 18" 427623D4A10 1 1.95 inti mo wheels
5 Repl Info label TPMS 42769T20000 1 1.92 RIALTO
** 501- _Repl Non OEM Vin label 1 124.95
m...
FRONT BUMPER & GRILLE
R&I R&I bumper cover as an assy 1.4
9 FRONT LAMPS
R&T LT R&I headlamp assy 0.3"
10 ....
11 FENDER
12 * BInd LT Fender 1.0
13 R&I LT Fender liner LX, EX, Sport 0.4
14 R&I LT Fender ledge cvr 0.2
15 R&I LT Wheel opng midg 0.3
16 PILLARS, ROCKER & FLOOR
Rpr LT Aperture panel 4.0 10
Note: REPAIR SMASHED IN ROCKER
18 Add for Clear Coat 0.4
19 # Rpr Body Pull 1.0
20 # Rpr Set Up On Floor 1.0
21 R&I LT Front sill plate 0.2
22 R&I LT Lwr ctr pir trim LX, EX, Sport, 0.3
Sport-L
23 R&I LT Rear sill plate 0.2
24 R&I LT Upr ctr plr trim black 0.3
25 R&I LT Cowl trim LX, EX, Sport, 0.2
Sport-L
26 # Refn Clear Coat Undamaged Panel- LT 0.5
ROCKER
27 # Refn Clear Coat Undamaged Panel-LT 0.5
HINGE PILLAR
28 FRONT DOOR
29 Repl USED LT door assy +20% 670503A0AOOZZ 1 912.00 1.6 3.2 Note: PER K&P SHELL ONLY
30 Overlap Major Adj. Panel -0.4
31 Add for Clear Coat 0.6
32 * S02 Repl LT Mirror assy w/o heat 762583A0A92 1 558.00 0.5 Note: Mirror from National Auto Body is aftermarket and not capa. 33 Refn LT Mirror cover gray metallic 0.4
34 Overlap Minor Panel -0.2
35 Add for Clear Coat 0.1
36 # Flex Additive 1 12.00 T
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Supplement of Record 3 with Summary
..O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK OF Note: Need for Mirror Cover Refinish
RIALT
resistance, chip resistance, and UV protection.
37 Repl LT Belt molding
38 Repl LT Frame molding
Note: PARTS: Part cannot be reused/reinstalled.
39 Repl LT Applique 724703A0A01 1 10.25 0.2
Note: PARTS: Part cannot be reused/reinstalled.
40 Repl LT Corner molding 724963A0A01 1 1.17
41 ** Repl Non OEM LT Body side midg 753323A0A01 1 122.00 0.4 42 Refn LT Handle, outside w/o smart 0.4
entry gray metallic
43 Overlap Minor Panel -0.2
44 Add for Clear Coat 0.1
45 * R&I LT Handle base w/o smart entry 0.1
46 * R&I LT Latch 0.4
47 * R&I LT Handle, inside w/o illumination 0.1
48 R&I LT Striker 0.2
49 R&I LT Lower hinge 0.3
50 R&I LT Upper hinge 0.3
51 R&I LT Window regulator EX, EX-L, 0.4
Sport
52 R&I LT Door glass Honda w/o acoustic 0.3
layer
53 R&I LT 'strip on body 0.4
54 R&I LT Water deflector 0.1
55 R&I LT Door 'strip 0.4
56 * S01 Repl LT Mirror cover black pearl 762513WOA11ZF 1 23.24 Incl. 0.0 57 * S01 Repl LT Door shell bumper #2 72142SM4000 1 7.53 58 REAR DOOR
59 * Rpr LT Outer panel 4.0 2.2
60 Overlap Major Adj. Panel -0.4
61 Add for Clear Coat 0,4
62 # Refn Base Coat Reduction - Full Clear -0.2
Coat
63 R&I LT W'strip on body 0.4
64 R&I LT R&I door assy 1.0
Note: R&I FOR REFINISH ACCESS TO APETURE
65 Repl LT Belt molding 729503A0A01 1 39.79 0.3
66 R&I LT Wheel opng midg 0.2
67 R&I LT Handle, outside gray metallic 0.3
68 R&I LT R&I trim panel 0.4
69 Repl LT Body side midg 7533333A0A01 1 143.43 0.4
70 QUARTER PANEL
71 S03 Repl LT Protector 744523A0A00 1 50.09 0.2
Note: MORE COST EFFECTIVE TO REPLACE VS CLEAN AND RETAPE 13/2025 4:40:27 PM 036535 Page 3
Supplement of Record 3 with Summary
..O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK CIT 72 VEHICLE DIAGNOSTICS oF
73 # Pre-repair scan 1 40.00 X
74 # S01 Post-repair scan 1 Incl. X
1 400.00 X RIALTO
75 # 503 Subl Static Calibration - Adaptive
Cruise Control
76 S03 Subl Static Calibration - Lane Keep 1 400.00 X
Assist
77 # S03 Electronic Stability Control 1 150.00 X M
Relearn
Note: Completed due to DTC C0051-54 Steering Angle
Neutral Position Learning Incomplete
78 503 Subl Clear Codes 1 125.00 X
79 # 503 Subl On-Board Calibration - O point 1 150.00 X calibration/ seat weight sens
80 # 501 Corrosion Protection - 1/4 can 1 T 0.2
81 # Rpr D&R Battery 0.1
82 # Subl Hazardous Waste 1 5.00 x
83 # Mask Interior for Overspray 1 0.3
84 # Cover Car for Overspray 1 5.00 X 0.2
85 # S01 Subl Fuel Surcharge. 1.00 X
86 # S01 Subl Fuel Surcharge. 1.00 X
87 # S01 Subl Fuel Surcharge 1.00 X
88 # 501 Subl Fuel Surcharge 1 1.00 X
89 503 REAR DOOR: LT Front applique 1
90 ** 503 Non OEM B-Pillar [Left] - Qty: 1 5.00
0.09 (Can(s)) - 3M Weid thru
coating
Note: CORROSION PROTECTION FOR CENTER PILLAR REPAIR
SUBTOTALS 3,365.24 24.9 9.4
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 2,074.24
Body Labor 24.9 hrs @ $62.00/hr 1,543.80
Paint Labor 9.4 hrs $62.00/hr 582.80
Paint Supplies 9.4 hrs @ $44.00 /hr 413.60
Miscellaneous 1,291.00
Pre-Tax Discount -1.0% -59.05
Subtotal 5,846.39
[4) 000093 $2,474.84 7.7500 %
Sales Tax @ 191.80
Grand Total 6,038.19
Deductible 1,000.00
CUSTOMER PAY 1,000.00
000093 4JJRPWTK31 CF0214P1 35 INSURANCE PAY 5,038.19
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Supplement of Record 3 with Summary
..O Number: 3023973 CITY
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK
SUPPLEMENT SUMMARY
ALT
Line Oper Description Part Number Qty Extended Labor Fie Paint Price $
Deleted Items
70 QUARTER PANEL
71 S01 R&I LT Protector -0.2
72 # 501 Repl Clean and Retape Moldings 1 -3.00 T -1.0
NOTE: CLEAN & RETAPE MOLDING
CLEAN OLD GLUE FROM QTR
76 # S02 Subl Static Calibration - Adaptive 1
Cruise Control
77 # S02 Subl Static Calibration - Lane Keep 1
Assist
78 # S01 Electronic Stability Control 1 -150.00 X
Relearn
79 # S01 Subl Clear Codes 1 -125.00X
80 # 502 Subl On-Board Calibration - Zero point 1
calibration
Added Items
70 QUARTER PANEL
71 S03 Repl LT Protector 744523A0A00 1 50.09 0.2
NOTE: MORE COST EFFECTIVE TO REPLACE VS CLEAN AND RETAPE 75 # 503 Subl Static Calibration - Adaptive 1 400.00 X
Cruise Control
76 # 503 Subl Static Calibration - Lane Keep 1 400.00 X Assist
# 503 Electronic Stability Control 1 150.00 X M
Relearn
NOTE: Completed due to DTC C0051-54 Steering Angle
Neutral Position Learning Incomplete
78 # S03 Subl Clear Codes 125.00 X
79 # 503 Subl On-Board Calibration - O point 150.00 X
calibration/ seat weight sens
89 # 503 REAR DOOR: LT Front applique
90 ** S03 Non OEM B-Pillar [Left] - Qty: 1 5000
0.09 (Can(s)) - 3M Weld thru
coating
NOTE: CORROSION PROTECTION FOR CENTER PILLAR REPAIR
SUBTOTALS 1,002.09 -1.0 0.0
35 14 000093 4 JJRPWTK31 CF0214P 1 35 [4] 000093
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Supplement of Record 3 with Summary
..O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK
TOTALS SUMMARY
Category Basis Rate z costs
Parts C 55.09
Body Labor 0.2 hrs @ $62.00/hr 12.40%-
Additional Supplement Labor -74.40
Miscellaneous : 947.00
Pre-Tax Discount -1.0% -9.40
Subtotal 930.69
Sales Tax $ 51.57 @ 7.7500 % 4.00
Total Supplement Amount 934.69
NET COST OF SUPPLEMENT 934.69
CUMULATIVE EFFECTS OF SUPPLEMENT(S)
Estimate 4,800.45 Eduardo Galvan
Supplement 501 1,342.48 Eduardo Galvan
Supplement S02 -1,039.43 Eduardo Galvan
Supplement S03 934.69 Eduardo Galvan
Job Total: $ 6,038.19
CUSTOMER PAY: $ 1,000.00
INSURANCE PAY: $ 5,038.19
35 15 000093 4JURPWTK31 CF0214P1 35 [4) 000093
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Supplement of Record 3 with Summary
..O Number: 3023973 ciT
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK ===========
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 cambe 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. 24/7/365 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
THIS IS NOT AN AUTHORIZATION TO REPAIR. TO ENSURE REPAIRS WILL BE COMPLETED BASED ON THIS ESTIMATE; PLEASE PROVIDE A COPY TO THE REPAIR FACILITY PRIOR TO AUTHORIZING REPAIRS. FAILURE TO DO SO MAY RESULT IN YOU BECOMING RESPONSIBLE FOR PAYING UNAPPROVED EXPENSES. ***SUPPLEMENTAL REQUESTS*** NO PAYMENT FOR A SUPPLEMENT WILL BE APPROVED OR ISSUED UNLESS THE REPAIRS WERE AUTHORIZED PRIOR TO COMPLETING THE SUPPLEMENTAL REPAIRS. POTENTIALLY, A REINSPECTION MAY BE CONDUCTED. ALL SUPPLEMENTS MUST BE APPROVED BY A CLAIMS REPRESENTATIVE BEFORE REPAIRS ARE COMPLETED.
*** RENTAL COVERAGE*** BASED ON OUR ESTIMATE WE HAVE CALCULATED THE DAYS TO REPAIR YOUR VEHICLE AND THIS INFORMATION IS LOCATED ON THE FRONT PAGE OF YOUR ESTIMATE. THIS APPLIES IF YOU HAVE RENTAL COVERAGE AVAILABLE OR HAVE BEEN APPROVED FOR A RENTAL VEHICLE. REQUESTS FOR A RENTAL EXTENSION MUST BE REVIEWED PRIOR TO AUTHORIZATION. IF YOUR VEHICLE IS SAFELY DRIVABLE, IT
SHOULD NOT BE LEFT FOR REPAIRS UNTIL THE NECESSARY PARTS ARE AVAILABLE AND YOUR REPAIR FACILITY IS READY TO COMMENCE REPAIRS. IF YOU LEAVE YOUR SAFELY DRIVABLE VEHICLE WITH THE REPAIR FACILITY
BEFORE PARTS ARE AVAILABLE, YOU WILL BE RESPONSIBLE FOR ANY UNNECESSARY RENTAL EXPENSES INCURRED DURING REPAIRS.
35 16 000093 4JJRPWTK31 CF0214P1 35 (4] 000093
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Supplement of Record 3 with Summary
..O Number: 3023973 Sibl CIT
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK THANK YOU FOR CHOOSING THE GUARANTEED REPAIR PROGRAM. OF If you have coverage for damage to your vehicle under this policy it is our obligation to inform you that Underr California Code of Regulations, Title 10, Chapter 5, Section 2695.8(e) you have the right to select the vehicle repair. facility of your choice.
WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US.
WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF•YOU
AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO
BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE.
AUTO BODY REPAIR CONSUMER BILL OF RIGHTS
A CONSUMER IS ENTITLED TO:
1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY SHALL NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP.
2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT.
3. BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES.
4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED.
5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS.
6. SEEK AND OBTAIN AN INDEPENDENT REPAIR ESTIMATE DIRECTLY FROM A REGISTERED AUTO BODY REPAIR
SHOP FOR REPAIR OF A DAMAGED VEHICLE, EVEN WHEN PURSUING AN INSURANCE CLAIM FOR REPAIR OF THE VEHICLE.
COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR Complaints concerning the repair of a vehicle by an auto body repair shop should be directed to:
Toll Free (866) 799-3811
California Department of Consumer Affairs
Bureau of Automotive Repair
10240 Systems Parkway
Sacramento, CA 95827
The Bureau of Automotive Repair can also accept complaints over its web site at: www.autorepair.ca.gov
COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER 35 17 000093 4JJRPWTK31 CF0214P1 35 (4) 000093 Any concerns regarding how an auto insurance claim is being handled should be submitted to the California Department of Insurance at:
(800) 927-HELP or (213) 897-8921
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Supplement of Record 3 with Summary
..O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK CIT SEST
California Department of Insurance g31
Consumer Services Division
300 South Spring Street, Soth Tower
RIALTO
Los Angeles, CA 90013
We must be notified by the repair facility, and physically inspect, all requests for supplemental damage. Failure to provide adequate notice may result in nonpayment of additional charges not contained in this appraisal.
ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
If you have coverage for damage to your vehicle under this policy it is our obligation to inform you that Under California Code of Regulations, Title 10, Chapter 5, Section 2695.8(e) you have the right to select the vehicle repair facility of your choice.
WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US.
WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU
AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO
BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF
YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASECONTACT US IMMEDIATELY FOR ASSISTANCE.
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.
DISCLAIMER
This warranty and any representations made herein are non-transferable and its benefits extend only to the party owning the vehicle at the time of the repair. It is not part of your insurance policy and does not constitute an extension of coverage there under.
This is not an authorization for repairs. Moreover, we must inspect and approve any and all supplementary damages prior to repair. If, after we have authorized repair, you fail to present this estimate to the repair facility prior to the start of repairs, you may incur additional expense.
(4) 000093
4JJRPWTK31 CF0214P1 35
660000
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Supplement of Record 3 with Summary
..O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK 2025 FEB 24 10 FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO Sin APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS FALSE RIALTO OR FRAUDULENT INFORMATION TO OBTAIN OR AMEND INSURANCE AMII: 24
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 (4) 000093 ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE.
14P1
4JJRPWTK31 CF02*
000093
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Supplement of Record 3 with Summary
-O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.OL Hybrid Gasoline Direct Injection BLACK Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Untess otherwise noted, (a) all items are derived from the Guide ARG4469, CCC Data Date 01/09/2025, 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 2024 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. CFC=Carbon Fiber.
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&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. Sect=Section. STS=Stainless Steel. Subl=Sublet.
UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Intelligent Solutions 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 35 20 000093 4JJRPWTK31 CF0214P1 35 [4] 000093 Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 13/2025 4:40:27 PM 036535 Page 11
Supplement of Record 3 with Summary
..O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK Fraud Language: 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 e payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
THIS REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. YOUR INSURANCE
COMPANY WILL STAND BEHIND THE QUALITY REPLACEMENT PARTS SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. YOUR INSURANCE COMPANY"
WARRANTS THESE PARTS ARE OF LIKE KIND, QUALITY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY ::
REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR AND TEAR.
SHOULD A SUPPLIER OF A PART SPECIFIED IN THE REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY
REPLACEMENT PART USED IN THE REPAIR, YOUR INSURANCE COMPANY WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS CORRECTED.
THIS QUALITY REPLACEMENT PARTS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE
NON-TRANSFERABLE AND EXTEND ONLY TO THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR. FOR ASSISTANCE, PLEASE CONTACT YOUR INSURANCE COMPANY'S NEAREST CLAIM DEPARTMENT OFFICE.
As the vehicle owner, the final choice as to which parts will actually be used in the repairs is yours. If you prefer parts other than those included on the estimate, you should notify your repair facility. Should the use of those other parts increase the repair cost, you will be expected to pay the difference. 35 21 000093 4JJRPWTK31 CF0214P1 35 [4] 000093
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Supplement of Record 3 with Summary
..O Number: 3023973
2023 HOND CR-V Hybrid Sport FWD w/o Blind Spot Info 4D UTV 4-2.0L Hybrid Gasoline Direct Injection BLACK PARTS SUPPLIER LIST RIALTO RIAL.
Line Supplier Description
29 K & P AUTO DISMANTLERS #9.24 7 $ 760.00€
15295 Whittram USED LT door assy +20%
Fontana CA 92335 LT FRONT DOOR-LT FRT DOOR SHELL,S#9.24 (909) 428-6898 Quote: 3175758315
Expires: 01/17/25
41 Keystone, Inc #H01304113 $122.00
15895 VALLEY BLVD, SUITE 100 Non OEM LT Body side midg
FONTANA CA 92335 Quote: 2787296663
(800) 421-7866 Expires: 02/01/25
35 22 000093 4JJRPWTK31 CF0214P1 35 [4] 000093
'13/2025 4:40:27 PM 036535 Page 13
THUAM
For Customer Support reter to the
appropriate plattorm below
• LexisNexis®
Police Records Retrieval
RISK SOLUTIONS 800-934-9698
[email protected]
For tips on ordering visit:
statetips.lexisnexisrisk.com Accurint for Insurance
866-277-8407
[email protected]
PAGE COUNT: 12
CLIENT: 207857
DIVISION: 12
ADJUSTER: USW9KYO9
CLAIM: 7008470706-1
TRANSACTION #: 3032690652
DATE: 2025-02-06 22:52:49.0
DATE OF LOSS: 12/13/2024 TIME OF LOSS: 19:30
STREET: E BASELINE RD & NORTHSIDE SYCAMORE AVE
CITY: RIALTO
COUNTY: SAN BERNARDINO
STATE: CA
INVESTIGATING AGENCY: CA HP
REPORT NUMBER: NCIC9860
REPORT TYPE: AUTOACCIDENT
PARTY1: NO NAME GIVEN SOHNU
PARTY2:
PARTY3:
CAR: CR-V MAKE: HONDA YEAR: 2023
TAG:
[4] 000093 ADDITIONAL INFO: INSURED VEHICLE HIT BY CLAIMANT VEHICLE NOTE: INSURED VEHICLE HIT BY CLAIMANT VEHICLE
4JJRPWTK31 CF02
THANK YOU FOR YOUR ORDER!
000093
STATE OF CALIFORNIA DEPARTMENT OF CALIFORNIA HIGHWAY PATROL TRAFFIC CRASH REPORT Page 1 of 11
CHP 555 Page 1 (Rev. 2-22) OPI 060
JUDICIAL DISTRICT LOCAL REPORT NUMBER
SPECIAL CONDITIONS UMBER THIT & RUN CITY
NJUREG FELONY SAN BERNARDINO SUPERIOR COURT FONTANA
OURTESY REPOR RIALTO COURTHOUSE 9865-2024-00557
N-DUTY EMERGENCY VEHICL 0
REPORTING DISTRICT BEAT DAY OF WEEK TOW AWAY
NUMBER KIT 8 RUN COUNTY
KILLED MISOEMEANOR
SAN BERNARDINO SM T W G EYES A NO
CRASH TIME (2400) | NOTIF. TIME (2400) NCIC # OFFICER D CRASH OCCURRED ON 12/1372024 CRASH DATE EAR
1923 12/13/2024 1926
N SYCAMORE AVE
STATE MAY REL DIGITAL MED
LAT INTERSECTION WITH EYES
OR: 150 FEET NORTH of BASELINE RD •YES[X] NO ENO EMBEDDED PS COORDINATES FOR LOCATION (LOC.) AND AREA(S) OF IMPACT (AI) LONG. LONG. 5° AT LAT. ISAME ASLOCATION 34.121670 O-117.366072
LOC. -117.366025 34.121577 -117.366025
34.121577
A01 | LAT. LONG. LAT.
LONG
34.121679 -117.366083
SAFETY EQUIP. VEH. YEAR MAKEMODELICOLOR LICENSE NUMBER STATE
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG CAF
CA M1 P 2024 BMW R1250 RT BLK/WHI
DRIVER NAME (FIRST, MIDDLE, LAST) ON-DUTY EMERGENCY VEHICLE * DANIEL JAMES SMITH OWNER'S NAME SAME AS DRIVER
PEDES: STREET ADDRESS THE CITY OF RIALTO
TRIAN OWNER'S ADDRESS • SAME AS DRIVER
128 N WILLOW AVENUE
PARKED CITY/STATEIZIP 150 S PALM AVE RIALTO RIALTO CA 92376 VEHICLE DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER [X] DRIVER •OTHER RIALTO CA 92376
BIcY. SEX EYES HEIGHT TWEIGHT BIRTHDATE Year RACE DRIVEN AWAY THAIR
Mo.
CLIST PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE M BRN BLUR 5'10" 230 W
HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
OTHER
MOTORCYCLE - LEFT
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
NONE (909) 820-2550
LUNK. NONE MINOR
INSURANCE CARRIER POLICY NUMBER
49 ALUK
SELF INSURED •NOD. MAJOR X ROLL-OVER
CITY OF RIALTO
LANE THRU TOTAL SPEED
DIR OF ON STREET OR HIGHWAY CA DOT
LANES SLAN-S
TRAVEL
CAL-T TCPIPSC ,MCIMX
N N SYCAMORE AVE N/B
SAFETY EQUIP. VEH. YEAR LICENSE NUMBER STATE
PARTY DRIVER S LICENSE NUMBER STATE CLASS AIR BAG MAKE/MODEL/COLOR M G 2023 HOND CRV BLK CA
CA
DRIVER NAME (FIRST MIDDLE. LAST)
SOHNU NO GIVEN NAME OWNER'S NAME X SAME AS DRIVER
STREET ADDRESS
OWNER'S ADDRESS X SAME AS DRIVER
PARRED CITY/STATE/ZIP
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER X DRIVER OTHER HAYWARD CA 94544
BICY. HAIR EYES HEIGHT WEIGHT BIRTHDATE You RACE DRIVEN AWAY SEX Mo.
CUST PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE BLK BLK 5'8" 161
HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
OTHER
NONE VEHICLE TYPE DESCRIBE VEMICLE DAMAGE SUV - LEFT
UNK. NONE
OPER- INSURANCE CARRIER POLICY NUMBER
ATOR 07 MAJOR ROLL-OVER
TAUYPVKULX MOD.
TOGGLE
DIR OF LANE THRU | TOTAL | SPEED DOT.
TON STREET OR HIGHWAY LANES LANES LIMIT CA
TRAVEL
N NSYCAMORE AVE N/B 40 CAL-T TCPIPSC_
SAFETY EQUIP. VEH. YEAR LICENSE NUMBER STATE
STATE CLASS AIR BAG MAKE/MODEUCOLOR
PARTY DRIVER'S LICENSE NUMBER
3 DRIVER NAME (FIRST MIDDLE, LAST)
OWNER'S NAME •SAME AS DRIVER
FEDES. STREET ADDRESS
TRIAN OWNER'S ADDRESS SAME AS DRIVER
PARKED CITYISTATEIZIP
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER •OTHER BICY- SEX THAIR EYES [HEIGHT TWEIGHT RACE
CUST PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE 35 24 000093 4JJRPWTK31 CF0214P1 35 [4] 000093 HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
OTHER
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
OPER POLICY NUMBER DUNK. NONE • MINOR
INSURANCE CARRIER
ATOR •MOD. • MAJOR | ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRL CA
TRAVEL LANES LANES
CAL-T TCPIPSC
DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED
PREPARER'S NAME
I.UIS A LOPEZ, 024041 •YES • NO X NIA
An Internationally Accredited Agency Destroy Previous Editions
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC CRASH CODING Page 2 of: 11
CHP 555 Page 2 (Rev. 2-22) OPI 060
OFFICER ID NUMBER
CRASH DATE (MO. DAY YEAR) CRASH TIME 2400) NCIC #
9865-2024-00557
12/13/2024 1923
PROPERTY OWNER'S NAME OWNER'S ADDRESS
DAMAGE (MARK ALL THAT APPLY) LOG / INCIDENT NUMETER.
PERSON NOTIFIED L SAME AS OWNER TELEPHONE NUMBER METHOD OF NOTIFICATION IN PERSON PHONE DISPATCH TCHP 422
DESCRIPTION OF DAMAGE
SAFETY EQUIPMENT AIR BAG INATTENTION COPES
SEATING POSITION
OCCUPANIS CHILD RESTRAINI - A BAG DEPLOYEE 4 - CELLPHONE HANDHELI A - NONE IN VEHICLE Q - IN VEHICLE USED 1 - AIR BAG NOT DEPLOYEI - CELLPHONE HANDSFREI 1 TO 9 - STANDARD SEATING B - UNKNOWN R - IN VEHICLE NOT USED C - ELECTRONIC EQUIPMENT
C - LAP BELT USED - OTHE D- RADIO / CD
POSITION S - IN VEHICLE USE UNKNOWN - NOT REQUIRE
D - LAP BELT NOT USED T - IN VEHICLE IMPROPER USE E - SMOKING 10 - REAR OCC. TRK., VAN, E - SHOULDER HARNESS USED U - NONE IN VEHICLE F - EATING 1 2 3 F - SHOULDER HARNESS NOT USED EJECTED FROM VEHICLE G - CHILDREN STATION WAGON, ETC.* • NOT EJECTE
456 G - LAP/SHOULDER HARNESS USED M / C BICYCLE. HELMEI • FULLY EJECTE H - ANIMALS 11 - POSITION UNKNOWN' H - LAP/SHOULDER HARNESS NOT USED DRIVER PASSENGER 1 - PERSONAL HYGIENE 7 8 9 J- PASSIVE RESTRAINT USED • PARTIALLY EJECT
V - NO X- NO - UNKNOV J- READING
K- PASSIVE RESTRAINT NOT USED W-YES Y - YES < - OTHER
10 O. OTHER*
P• NOT REQUIRED
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY CRASH FACTOR TRAFFIC CONTROL DEVICES 2 3 VEHICLE AUTOMATION LEVEL 12 3 MOVEMENT PRECEDING CRASH LIST NUMBER (#) OF PARTY AT FAULT
CVC SECTION VIOLATED GTED A CONTROLS FUNCTIONING X A SAE LEVEL - O A STOPPE A VC 21750(a) YES B CONTROLS NOT FUNCTIONING* B SAE LEVEL - 1 B PROCEEDING STRAIGH IN NO
C CONTROLS OBSCURED C SAE LEVEL - 2 C RAN OFF ROAD
B OTHER IMPROPER DRIVING*: X D NO CONTROLS PRESENT / FACTOR* D SAE LEVEL - 3 D MAKING RIGHT TURN TYPE OF CRASH E SAE LEVEL • 4 MAKING LEFT TURN
C OTHER THAN DRIVER* F MAKING U TURN
D UNKNOWN* A HEAD - ON F SAE LEVEL - 5
G UNKNOWN* G BACKING
X B SIDE SMPE
H SLOWING / STOPPING
C REAR END 2 VEHICLE AUTOMATION ENGAGED
PASSING OTHER VEHICLE
WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE
E HIT OBJECT X A NO AUTOMATION CHANGING LANES
X A CLEAR K PARKING MANEUVER
F OVERTURNED B DRIVER ASSISTANCE
B CLOUDY
C PARTIAL AUTOMATION L ENTERING TRAFFIC
RAINING G VEHICLE / PEDESTRIAN
D CONDITIONAL AUTOMATION M OTHER UNSAFE TURNING
D SNOWING H OTHER*:
MOTOR VEHICLE INVOLVED WITH E HIGH AUTOMATION IN XING INTO OPPOSING LANE FOG / VISIBILITY FT.
(MARK 1 TO 2 (TEMS) F FULL AUTOMATION O PARKED
F OTHER*: P MERGING
A NONCOLLISION G UNKNOWN*
G WND
B PEDESTRIAN Q IRAVELING WRONG WAY
LIGHTING
X TC OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS) R OTHER • A DAYLIGHT 2 3 (MARK 1 TO 2 ITEMS)
D MOTOR VEHICLE ON OTHER ROADWAY S LANE SPLITTING
DUSK - DAWN
E PARKED MOTOR VEHICLE EVC SECTION VIOLATION CITED. SOBRIETY - DRUG X DARK - STREET LIGHTS A YES 3 BRAT A THAT APPLI
F TRAIN NO
D DARK - NO STREET LIGHTS X HAD NOT BEEN DRINKING
G BICYCLE CVC SECTION VIOLATION
E DARK - STREET LIGHTS NOT B YES
B HBD - UNDER INFLUENCE
FUNCTIONING* H ANIMAL: INO
C/C SECTION VIOLATION C HBD - NOT UNDER INFLUENCE*
ROADWAY SURFACE 1 FIXED OBJECT: •YES
•NO D HBD - IMPAIRMENT UNKNOWN
X A DRY E UNDER DRUG INFLUENCE* :
B WET J OTHER OBJECT:
E VISION OBSCUREMENT: DRE EXAM. CONDUCTED
C SNOWY - ICY STIMULANT
K ADDITIONAL OBJECTS) STRUCK F INATTENTION®
D SLIPPERY (MUDDY, OILY. ETC.) HALLUCINOGEN
ROADWAY CONDITION(S) PEDESTRIAN'S ACTIONS G STOP & GO TRAFFIC
H ENTERING / LEAVING RAMP DISSOCIATIVE ANESTHETICS
(MARK 1 TO 2 ITEMS) X A NO PEDESTRIANS INVOLVED
PREVIOUS CRASH NARCOTIC ANALGESIC
A HOLES. DEEP RUT* B CROSSING IN CROSSWALK INHALANT
B LOOSE MATERIAL ON ROADWAY AT INTERSECTION J UNFAMILIAR WTH ROAD C OBSTRUCTION ON ROADWAY• : CROSSING IN CROSSWALK - NOT K DEFECTIVE VEH. EQUIP. ATE YES CANNABIS AT INTERSECTIOI •NO DEPRESSANT
D CONSTRUCTION - REPAIR ZONE IMPAIRMENT - PHYSICA
LE REDUCED ROADWAY WDTH D CROSSING - NOT IN CROSSWALK L UNINVOLVED VEHICLE É INROAD - INCLUDES SHOULDER M OTHER* ; IMPAIRMENT NOT KNOW F FLOODED•
G OTHER: F NOT IN ROAD N NONE APPARENT H NOT APPLICABLE
G APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE SLEEPY / FATIGUED
SEEM NO UNUSUA CONDITTONS MISCELLANEOUS SPECIAL INFORMATION 12 3
35(4) 000093 REFER TO SKETCH PAGES) A HAZARDOUS MATERIAL
INDICATE NORTH B CELL PHONE HANDHELD IN USE
COSE PHONE HANDSFREE IN
ID CELL PHONE NOT IN USE
E CELL PHONE USE UNKNOWN
IF SCHOOL BUS RELATED
35 25 000093 4JJRPWTK31 CF0214P1 12 BIKEWAY FACILITY
A SHARED ROADWAY
B CLASS I - BIKE PATH•
C CLASS II - BIKE LANE*
D CLASS III - BIKE ROUTE
E CLASS IV - SEPARATE
REFER TO NARRATIVE FOR ADDITIONAL INFORMATION BIKEWAY
An Internationally Accredited Agency
OF CALIFORNIA
TATMN CALIFORNA HIGHWAY PATRO
INJURED / WITNESS / PASSENGERS Page 3 of 11
CHP 555 Page 3 (Rev. 2-22) OPI 060
CRASH TIME (2400) NCIC 8 OFFICER ID NUMBER
CRASH DATE (MO DAY YEAR)
9865-2024-00557
12/13/2024 1923
EXTENT OF INJURY ("X" ONE) INJURED WAS ("X" ONE) PARTY
SEAT AIR SAFETY EJECTED
WITNESS PASSENGER AGE SEX NUMBER POS. BAG EQUIP.
ONLY ONLY FATAL SUSPECTED SERIOUS SUSPECTED MINOR POSSIBLE BICYCLIST OPER. 26 M 3 CM
TELEPHONE
NAME / D. O. B. / ADDRESS • (S10) 395-7080/NONE
SAHIL KUMAR (08/05/1998) 1431 163RD AVE APT 10 SAN LEANDRO CA 94578 [EMS RUN NUMBER: TAKEN TO:
(INJURED ONLY) TRANSPORTED BY:
• C
DESCRIBE INJURIES 7
VICTIA OF VIOLENT CRIME NOTIMEDEA
'TELEPHONE
NAME / D. O. B. / ADDRESS
EMS RUN NUMBER: TAKEN TO:
(INJURED ONLY) TRANSPORTED BY:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
TELEPHONE
NAME / D. O. B.I ADDRESS
EMS RUN NUMBER: TAKEN TO:
(INJURED ONLY) TRANSPORTED BY:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
TELEPHONE
NAME / D. O. B. I ADORESS
(INJURED ONLY) TRANSFORTED BY: EMS RUN NUMBER: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
NAME / D. O. B./ ADDRESS
TAKEN TO:
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
U L
TELEPHONE
NAME / D. O. B. / ADDRESS
35 26 000093 4JJRPWTK31 CF0214P1 35 (4) 000093
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER: TAKEN TO.
DESCRIBE INJURIES
• VICTIM OF VIOLENT CRIME NOTIFIED
ID NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR
PREPARER'S NAME
LUIS A LOPEZ 024041 12/13/2024
An Internationally Accredited Agency
DEPARONENTOORALFORNA HIGHWAY PATROL
SKETCH DIAGRAM
CHP 555 Page 4 (Rev. 2-2Ø) OP| 060 Pagen4 of 11
OFFICER ID NUMBER
CRASHDATE (MO. DAY YEAR) CRASH TIME (2400) INCIC S
1923 9865-202400557
12/13/2024
Sir N°
DATE PREPARER CAPTURED IMAGE: 12/15/2024 RIALTO
PROPRIETOR OF IMAGE: Google
COPYRIGHT YEAR OF IMAGE: 2024
S
C
4 Googie
000093
35(4)
14P1
CF021
4JJRPWTK31 THIS OVERHEAD IMAGE IS PROVIDED TO DEPICT THE CRASH SCENE ENVIRONMENT ONLY. ANY VEHICLES,
PEDESTRIANS, OR OTHER ROAD USERS CAPTURED IN THE OVERHEAD IMAGE NOT DEPICTED IN THE 000093 SUMMARYICAUSE WERE NOT ASSOCIATED WITH THIS CRASH. 3527 ALL VEHICLE DIMENSIONS AND MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED.
REVIEWER'S NAME MO. DAY YEAR
PREPARED BY ID NUMBER TMO. DAY YEAR
LUIS A LOPEZ 024041 12/13/2024
An internationally Accredited Agency
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 5 OF 11
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
12/13/2024 1923 9865-2024-00557
1 All times, speeds, and measurements throughout this report are approximate. Measurements were 2 obtained using visual estimation and GPS unless otherwise stated. All opinions and conclușions were 3 based on evidence and/or statements.
4 5 OTHER FACTUAL INFORMATION:
7 Party #1 (P-1, Smith) at the time of the crash was an Officer with the Rialto Police Department as defined 8 in Penal Code section 830.1 and was on-duty wearing a Rialto Police Department uniform, while riding a 9 black and white authorized emergency vehicle (motorcycle) as described in California Vehicle Code section 10 165.
11 12 | observed P-1 had a departmentally issued DOT approved helmet, and it was completely intact 13 14 STATEMENTS:
15 16 Party #1 (P-1, Smith) was contacted within the Harbor Freight parking lot located at, 260 E Baseline Rd in 17 the city of Rialto. He related the following information to me: P-1 was riding Vehicle #1 (V-1, BMW) within 18 the northbound lane of N Sycamore Ave, north of Baseline Rd at approximately 15 miles per hour. P-1 19 was riding V-1 within the left portion of the northbound lane. P-1 observed V-2 slow down to 2-3 miles per 20 hour directly in front of him within the northbound lane. P-1 observed V-2 move to the right curb of N 21 Sycamore Rd. P-1 observed no turn signal from V-2. P-1 then moved V-1 to the left portion of the 22 northbound lane and proceeded past the driver door. As V-1 began to pass V-2 on the left, V-2 made a left 23 turn in V-1's direct path of travel. After the impact, P-1 picked up V-1 from the roadway and out of lanes. 24 Both parties relocated their respective vehicles to the Harbor Freight parking lot, and awaited CHP arrival. 25 26 Party #2 (P-2, SOHNU) was contacted within the Harbor Freight parking lot. Passenger #1 (Pass-1, 27 Kumar) translated for P-2. P-2 related the following information to me: P-2 was driving Vehicle #2 (V-2, 28 Honda) within the northbound lane of N Sycamore Ave, north of Baseline Rd, driving at a slow rate of 35 28 000093 4JJRPWTK31 CF0214P1 35(4] 000093 29 speed, approximately 2-3 miles per hour. P-2 used his left-hand turn signal to turn into the Harbor Freight 30 parking lot. P-2 related that V-1 rode up from behind and tried to pass V-2 on the left. As V-2 was making 31 a left-hand turn, V-1 hit the side of V-2.
I.D. NUMBER DATE REVIEWER'S NAME DATE
PREPARED BY
LUIS A LOPEZ 024041 12/13/2024
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 6 OF 11
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER,
12/13/2024 1923 9865-2024-00557
831
27 10
1 STATEMENTS (Continued):
10 3 P-2 stated he did not make a wide turn or swing to the right before turning into the parking lot r AMI1: 25 RIALTO 4 After the crash, P-2 relocated V-2 into the Harbor Freight parking lot and waited for CHP arrival. 5 6 SUMMARY/CAUSE:
7 8 Party #1 (P-1, Smith) was riding Vehicle #1 (V-1, BMW) within the northbound lane of N Sycamore Ave, 9 north of Baseline Rd at approximately 2-15 miles per hour. V-1 was approaching the left rear of V-2. Party 10#2 (P-2, Sohnu) was driving Vehicle #2 (V-2, Honda) within the northbound lane of N Sycamore Ave, 11 north of Baseline Rd, at approximately 2-15 miles per hour and intending to make a left turn into a private 12 driveway located at 260 E. Baseline Rd. P-1 began to overtake V-2 on the left as P-2 made a left-hand 13 turn into the driveway. Due to P-1's unsafe passing on the left (21750 (a) CVC) and failure to ensure his 14 path of travel was clear, the right front fairing of V-1 crashed into the left side of V-2 (AOl #1). After the 15 impact to V-2, V-1 overturned onto its side and onto the roadway (AOI #2). After V-1 impacted the 16 roadway, P-1 was ejected and fell into the roadway alongside V-1 (AOI #3). After the crash, P-1 was able 17 to stand V-1 upright. Both parties moved off the roadway and parked in the Harbor Freight parking lot 18 located at 260E. Baseline Rd. in the city of Rialto. Both parties remained on scene and awaited CHP 19 arrival.
1 35(4 000093
35 29 000093 4JJPWTK31 CF0214P
I.D. NUMBER DATE REVIEWER'S NAME DATE
PREPARED BY
LUIS A LOPEZ 024041 12/13/2024
TATE OF CALIFORN
EPARTMENT OF CALFORNIA HIGHWAY PATRO
PHOTOS
CHP 555 OPI 060
OFFICER ID NUMBER
DATE OF CRASH MO. DAY YEAR) TIME (2400) NCIC #
12/13/2024 1923 9865-2024-00557
CRV CRV
CITY OF RIALTO
AMII: 25
CRV CRV
35 30 000093 4JJRPWTK31 CF0214P1 35 (4) 000093
ID NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR
PREPARED BY
LUIS A LOPEZ 024041 12/13/2024
An internationally Accredited Agency
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
PHOTOS
CHP 555 OPI 060
OFFICER ID NUMBER
DATE OF CRASH MO. DAY YEAR) TIME (2400) NCK *
9865-2024-08557 D
12/13/2024 1923
CRV AM 11: ALTO
CRV
25 /er
RIALTO PD BIKE RIALTO PD BIKE
16 REVIEWER'S NAME MO. DAY YEAR
PREPARED BY ID NUMBER MO. DAY YEAR
LUIS A LOPEZ 024041 12/13/2024
An internationally Accredited Agency
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
PHOTOS
Sage 9 0111
CHP 555 OPI 060
OFFICER ID NUMBER
DATE OF CRASH (MO. DAY YEAR) TIME (2400)
9865-2024-00557
12/13/2024 1923
RIALTO PD BIKE RIALTO PD BIKE RIALTO
AM 11: 2
RIALTO PD BIKE RIALTO PD BIKE
35 32 000093 4JJRPWTK31 CF0214P1 35(4] 000093
MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR
PREPARED BY ID NUMBER
LUIS A LOPEZ 024041 12/13/2024
An internationally Accredited Agency
TE OF CALIFORN
ARTMENT OF CALFORNIA HIGHWAY PATR
PHOTOS
CHP 555 OPI 060
OFFICER ID NUMBER
DATE OF CRASH MO. DAY YEAR) TIME (2400) INCC *
12/13/2024 1923 9865-2024-00557
RIALTO PD BIKE RIALTO PD BIKE FEB
24 AMII: 25 ' OF RIALTO
RIALTO PD BIKE RIALTO PD BIKE
3013658
ID NUMBER MO. DAY YEAR REVIEWER'S NAME IMO. DAY YEAR
PREPARED BY
LUIS A LOPEZ 024041 12/13/2024
An Internationally Accredited Agency
DEPARTMENT FORNIA HIGHWAY PATROL
PHOTOS
CHP 555 OPI 060
OFFICER ID NUMBER
DATE OF CRASH (MO. DAYYEAR) TIME (2400) NCIC #
1923 9865-2024-00557
12/13/2024
RIALTO PD BIKE RIALTO PD BIKE
202F EEB 24 CITY OF RIALTO
AMI1: 26
RIALTO PD BIKE RIALTO PD BIKE
MO. DAY YEAR REVIEWERS NAME MO. DAY YEAR
PREPARED BY ID NUMBER
LUIS A LOPEZ 024041 12/13/2024
An internationally Accredited Agency
Email: [email protected]
Toggle™ Please include your claim # on any correspondence A Farmers Company National Document Cente
PO. Box 268994
Oklahoma City, OK 73126-8994
February 14, 2025 info. gettoggle.com/claims
Payment Log
Account Number: JJJ331648
Date of Loss: 12/13/2024
Insured's Name . SOHNU 2025 FEB 24
Claim Number: 7008470706-1 CITY OF RIALET
F2 AM
Unit Type Claim Unit Date Issued Payee Check Naper = mend Amount
Vehicle 01/16/2025 CALIBER COLLISION - RIALTO (MSO) 1641509872 i $$,038.19 Payment Total: $5,038.19
Collections Total : $0.00
Deductible: $0.00
Grand Total : $5,038.19
4JJRPWTK3 Page 34 of 34
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000093
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