CITY OF RIALTO P.O. Box 10730
A MERCURY Santa Ana, CA 92711-0730
INSURANCE 2025 MAR 10 AMIO: 10
RECEIVED
CITY CLERK
March 6, 2025
RIALTO CITY CLERK'S OFFICE
150 S PALM AVE
RIALTO, CA 92376
RE: OUR INSURED: MICHAEL GARCIA
OUR CLAIM NUMBER:
DATE OF LOSS: JANUARY 27, 2025
YOUR INSURED: UNKNOWN DRIVER
DEAR RIALTO CITY CLERK'S OFFICE:
We have obtained information suggesting that the damages incurred from the above-referenced loss were caused by your insured's negligence.
Enclosed for your review, please find copies of our supporting documentation. The breakdown of our payments is as follows:
Initial Repairs $2,392.65
Deductible $500.00
Supplements
Rental Expense
Out of Pocket Expense
Other
Salvage
VLF, if applicable
Total $2,892.65
Total Amount Due $2,892.65
Please review for payment. Thank you.
If we receive a payment that is less than the amount shown above, it will be processed and applied as a partial payment only.
This will not indicate any acceptance of liability or agreement to compromise the claim amount. Note that "Full or final settlement" or similar wording, whether on the payment itself or on accompanying correspondence, does not function as a Should you have any questions or need additional information, please do not hesitate to contact me. Thank you for your cooperation.
Sincerely,
California Automobile Insurance Company
Claims Department
888-263-7287
Encl.
C21 04/2021
CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2025 MAR 10 AMIO: 10
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
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 reall 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:
California Auto Insurance Company as subrogee of Michael Garcia
FULL NAME DATE OF BIRTH
L
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
ATTN: CAPA-02499170 PO Box 10730 Santa Ana, CA 92711 ( 888) 917-6372 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: 01/27/2025 TIME: 11:25 X 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. 210 FWY E/B at Ayala exit, Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
Our insured was exiting the 210 FWY E/B at Ayala exit. Our insured was in the center of three lanes and Rialto Fire Dept Ambulance was in the right lane, and when the light turned green the ambulance went forward and struck the p/s rear of our insured's vehicle. Ambulance was in the right turn only lane and went straight without using emergency lights or siren.
4. WERE POLICE AT THE SCENE? • YES • NO WERE PARAMEDICS AT THE SCENE? • YES ONO
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.
Unknown driver of Rialto Fire Dept Ambulance (License plate # CA 1608202) merged into our insured's vehicle.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2,892.65 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Repairs Amount: $2,392.65
Item/Date: Deductible Amount: $500.00
•
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $2,892.65 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY OF RIALTO Item/Date: 2025 MAR 10 AM IO: Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: RECEIVED s 2,892.65
CITY CLERK
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: |)
DATE: TIME: • AM • PM DATE: TIME: • AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street comers.
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
7. 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 BEUEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. on behalf of California Auto Insurance Company
SIGNATURE OF CLAIMANT OR AGENT
Tiffany Stallard on behalf of California Auto Insurance Company 03/06/2025
TYPE OR PRINT NAME DATE
Insurer
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376
CITY OF RIALTO
2025 MAR 10 AMIO: |1
RECEIVED
CITY CLERK
Scheduled Send Date Issue Date Check Number: Payment Channel: Payment Method Check Type Pay To Amount Status 03/03/2025 Digital Vendor Direct Deposit Indemnity CARSTAR AVALON COLLISION RIALTO $2,392.65 Cleared •
CITY OF RIALTO
CARSTAR AVALON COLLISION, BLANTO o AMID: I FINAL
2479 W Walnut Ave, Rialto, CA 92376-3014 Estimate ID
Office: (909) 742-7136 RECEIVED 21845976
CITY CLERK
[email protected] S2;
Carstar.com Claim Number
EPA: CAR000358234 Bar ID: ARD00306633 Tax ID: 923724604 CAPA-0249917000101 Owner Insured Appraiser
MICHAEL GARCIA MICHAEL GARCIA Brian Estrada
[email protected]
Classification
None
Supplemented By
Brian Estrada
[email protected]
Classification
None
MERCURY INSURANCE GROUP
Loss Type Claim Number Policy Number Adjuster
Collision CAPA-0249917000101 Fanny Campa
(888) 263-7287+27869 (Wor
Deductible Reported Date Loss Date Inspection Site
500.00 - Not Waived 01/27/2025 01/27/2025 CARSTARAVALON
COLLISION RIALTO
2479 WWalnut Ave
Rialto, CA 92376
Repair Facility
CARSTAR Avalon Collision
Rialto
2479W Walnut Ave
Rialto, CA 92376-3014
2011 Kia Soul + 4 Door Utility 2.0L 4 Cyl Gas Injected Base FWD Exterior Color License VIN Drivable
Silver Yes
Odometer Production Date Mitchell Service Code
188618 01/2011
Primary Point of Impact Secondary Points) of Impact
Right Rear Side (4) Right Rear Corner (5)
Committed On Version Printed On Profile Page 1 of7
3/3/2025 itchell Estimating 2 3/3/2025 Mercury
M FEB 25 11:52 AM Profile Version
11:52 AM 8.0
CITY OF RIALTO
Options
Air Conditioning Alum/Alloy Wheels AM-FM Stereo Anti-Lock Brake Sys. (2995 Mongtic Mendights l Auxiliary Input Bluetooth Wireless CD Player Cloth Seat Cruise Control Connectivity
Driver-Front Air Bag Electric Defogger Electronic Stability Control First Row Bucket Seat Left-Curtain Air Bag MP3 Player Passenger-Front Air Bag Power Door Locks Power Remote Mirror Power Steering Power Windows Privacy Glass Rear Bench Seat Rear Gate Wiper Satellite Radio Second Row Side Airbag With Side Airbags Steering Wheel Mounted Tilt Steering Wheel Head Protection Audio Control
Tire Pressure Monitoring Traction Control/Electronic Trip Computer System
MICHAEL GARCIA | 2011 Kia Soul +
Parts Profile Parts Profile Version
CA CARS Shop Profile 36.0
LABOR — - PART —
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax Rocker/ Pillars / Floor
1 100585 RRoof Rail Blend Refinish 0.6# C 1.6 Existing
≥ 900500 Clear Coat Adjustment- Refinish Refinish* -0.1* 0.0 Existing RT Roof Rail Only
Front Door
51 3 100656 RErt Add For Jambs Refinish Refinish 0.5 C 0.5 Existing Only
51 4 101386 RFrt Door Shell Repair Body 2.0*# 4.6 Existing 5 101388 R Frt Door Repair Panel Repair Body 3.0*# 6.6 Existing 6 AUTO R Frt Door Outside Refinish Refinish 2.0 C 2.0 Existing Only
7 100662 R Frt Rear View Mirror Remove / Body INC# 0.7 Existing Install
& 100664 R Frt Otr Door Belt Remove / Body 0.9# 0.9 Existing Moulding Install
9 100172 RFrt Door Moulding Remove / Body 0.2 0.2 New 87712 2K000 1 $40.14 Yes Replace
10 100668 RFrt Door Trim Panel Remove / Body INC 0.4 Existing Install
11 100595 RFrt Otr Door Handle Remove / Body 0.3# 0.7 Existing Install
12 900500 Basecoat reduction-RT FT Refinish Refinish* -0.2* 0.0 Existing Door Only
Rear Door
S2 13 101802 RRear Door Shell Remove / Body 4.3# 4.3 Qual Recycled RF6733 1 $134.00* Yes Replace Part
52 14 900510 Line Markup 20.0% $26.80
52 15 AUTO RRear Door Outside Refinish Refinish 1.6C 20 Only
s2 16 AUTO RRear Add For Jambs & Refinish Refinish 1.0 C 1.0 Interior Only
17 900500 LKQ Door Labor Additional Body* -0.3* 0.0 Existing Adjustment Labor
18 100498 RRear Door Front Remove / Body 0.2# 0.2 New 863912K000 1 $15.12 Yes Blackout Tape Replace
Committed On Version Mitchell Cloud Estimating™ Printed On Profile Page 2 of7 3/3/2025 Mitchell Estimating 24. 3/3/2025 Mercury
11:52 AM EM FEB_25_1 Copyright 1994-2025 Mitchell International, Inc. 11:52 AM Profile Version All Rights Reserved 8.0
CITY OF RIALTO
LABOR -- - PART
Line # Description Total Units CEG 20258R 10 AMber 1 Qty Total Price Tax Operation Type
19 100500 RRear Upr Door Blackout Remove / Body 0.2# 0.2 NeW ECEIV363922K000 1 $24.23 Yes Tape Replace
20 100502 R Rear Door Rear Remove / Body 0.2# 0.2 NeTY CL CL585932K000 1 $14.83 Yes Blackout Tape Replace
51 21 100504 R Rear Door Moulding Remove / Body INC 0.2 New 87722 2K000 1 $33.39 Yes Replace
22 102745 R Rear Door Protector Remove / Body 0.2# 0.2 New 87549 2K010 1 $18.70 Yes Replace
Roof
23 100155 R Roof Moulding Remove / Body 0.3 0.3 Existing Install
Quarter Panel
24 101282 R Quarter Outer Panel Repair Body 9.0*# 15.3 Existing 25 AUTO Quarter Panel Outside Refinish Refinish 1.6C 2.0 Existing Only
26 102747 Quarter Protector Remove / Body 0.2# 0.2 New 84126 2K000 1 $27.27 Yes Replace
Quarter Glass
27 101275 R Qtr Glass Stationary Remove / Body* 0.0*# 2.0 Sublet 1 $70.00* Replace
28 900510 Line Markup 20.0% $14.00
29 101761 Qtr Glass Adhesive Remove / Body 0.0 0.0 Aftermarket 1 $18.00* Yes Replace New
30 900510 Line Markup 20.0% $3.60
31 900501 RT Qtr Glass
Rear Lamps
32 100823 R Rear Combination Lamp Remove/ Body INC 0.4 Existing Install
Rear Bumper
33 100015 Rear Bumper Cover Remove / Body 1.4# 1.4 Existing Install
Additional Costs & Materials
34 AUTO Paint/Materials Additional $369.60 Yes
Cost
Additional Operations
35 AUTO Clear Coat Additional Refinish 1.8 0.0 $0.00
Operation
36 900500 Mask for Overspray Replace/ Body. 0.0* 0.0 Aftermarket 1 $10.00° New
37 933003 Tint Color Additional Body* 0.5* 0.0 $0.00
Operation
38 933017 Finish Sand And Buff Additional Body* 2.0° 0.0 $0.00 Operation
39 900500 Rope Windshield Additional Body* 0.3* 0.0 Existing Labor
51 40 900500 Pre Scan Additional Body* 0.5* 0.0 Existing Labor
51 41 900500 Post Scan Additional Mechanical* 0.5* 0.0 Existing Labor
* Judgment Item C Included in Clear Coat Calculation
T Included in Two Tone Calculation A Included in Clear Coat and Two Tone Calculation
# Labor Note Applies r CEG R&R Time Used for this Labor Operation Committed On Printed On Profile Page 3 of7
3/3/2025 Copital: 974-02 telenational. ne 3/3/2025 Mercury 11:52 AM Profile Version
11:52 AM All Rights Reserved 8.0
d Discontinued by Manufacturer [I Verify the part number and price before OF RIALTO ordering 2025 MAR IO AMIO: |I
New OEM
OE Discount OE Discount RECEIVED
Aftermarket New Aftermarket New CITY CLERK
Aftermarket Certified Aftermarket Certified
Remanufactured Remanufactured
Qual Recycled Part Quality Recycled Part
Sublet Sublet
Recored Recored
Rechromed Rechromed
Existing Existing
Recycled Part Vendors
LKQ-Keystone- Northern California
2850 Viking Way
Redding CA 96003
(800) 424-2002 (Work)
(630) 563-4022 (Work)
Line Part # Total Price Vehicle Description VIN
13 RF6733 $134.00 2012 Kia SOUL RH,1,5DR,WK R, (ELECTRIC), (RAISED OUTER
Supplier Notes: RH,1,5DR,WK R, (ELECTRIC), (RAISED OUTER Disclaimer: Recycled part pricing may represent either actual pricing (the price at which the recycler is willing to sell the part for in its existing condition) or undamaged pricing (the price at which the recycler would sell the part if it was in undamaged condition). If you are unsure, please contact the automotive recycler. Some parts located for this quote may be interchangeable but may not be an exact match. If you are unsure, please contact the automotive recycler.
Disclaimer: 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.
Estimate Totals
Labor Units Rate Sublet Add'l Amount Totals
Body Labor 25.4 $58.00 $1,473.20
Refinish Labor 8.8 $58.00 $510.40
Mechanical Labor 0.5 $85.00 $42.50
Total Labor 34.7 $2,026.10
Taxable $0.00
Tax 0.0000% $0.00
Non-Taxable $2,026.10
Pre-Tax Discount 0.00% $0.00
Labor Total $2,026.10
Parts Amount
Taxable Parts $325.68 $325.68
Committed On Version Printed On Profile Page 4 of7
Mitchell Cloud Estimating™ 3/3/2025 Mercury
3/3/2025 Mitchell Estimating 24. Copyright 1994-2025 Mitchell International, Inc Profile Version 11:52 AM DEM FEB_25_ All Rights Reserved 11:52 AM
8.0 CITY OF RIALTO
Estimate Totals
2025 MAR 10 AMIO: I Parts Adjustments $35.71
Tax 7.7500% $26.92
RECEIVED Non-Taxable $80.00
CITY CLERK Pre-Tax Discount 0.00% $0.00
Parts Total $468.31
Costs Amount
Paint Materials $369.60 $369.60
Shop Materials $0.00 $0.00
Other Additional $0.00 $0.00
Costs
Paint Materials: Taxable $369.60
- Refinish Units: 8.8 units Tax 7.7500% $28.64
- Rate: $42.00 Non-Taxable $0.00
- Rate Max: 99.9 units Pre-Tax Discount 0.00% $0.00
- Additional Rate: $650.00 Costs Total $398.24
Gross Totals Amount
Gross Total $2,892.65 $2,892.65
Taxable $716.99
Tax $55.56
Non-Taxable $2,120.10
Pre-Tax Discount 0.00% $0.00
Gross Total $2,892.65
Adjustments Amount
Deductible -$500.00 -$500.00
Total Customer -$500.00
Responsibility
Net Estimate Total $2,392.65
Less Original Net Total $2,151.68
Net Supplement Amount $240.97
S1: Brian Estrada $273.30
S2: Brian Estrada -$32.33
Disclaimer: For your protection California law requires the following statement to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Cycle Time Information Estimate Event Log
Due In 2/17/2025 Job Created 1/27/2025 12:38 PM
Supplement 2 Started 3/3/2025 11:50 AM
Arrived At Shop 2/17/2025 Supplement 2 Printed 3/3/2025 11:52 AM Ready for Delivery 2/26/2025 Supplement 2 Committed 3/3/2025 11:52 AM Delivered 2/26/2025 Estimate Version 3
Estimate Retrieval ID 1004662406
Committed On Version Printed On Profile Page 5 of7
3/3/2025 Mitchell Estimating 24.5 Copriat 15942025 Mitenel international, Inc 3/3/2025 Mercury 11:52 AM OEM FEB 25 V ll Rights Reserver 11:52 AM Profile Versio
8.0 •
CITY OF RIALTO
Delta Repots MAR 1O AM1O: 11
Supplement 1 & Supplement 2
RECEIVED
Date & Time Estimate ID Supplement No. CITY ProfielD
3/3/2025 21845976 Supplement 2 Mercury
11:52:43 AM
MICHAEL GARCIA MICHAEL GARCIA | 2011 Kia Soul +
Damage Assessed By Supplemented By Date of Loss
Brian Estrada Brian Estrada 01/27/2025
Global Changes
No Deductible, Deductible Reduction Credit, Insurance Pre-Paid Amount, Part Adjustments, or Related Prior Damage changes were made.
Estimate Line Changes - Primary Estimate
Supp/ - LABOR PART -
Line # Item Description Operation Type Total Units, CEG Type Number Price Changed Entries
51 13 RRear Door Shell Remove/ Body 4.30 4.30T Recycled RF6733 $159.00 Replace
13 RRear Door Shell Remove/ Body 4.30 4.30T Recycled RF6733 $134.00* Replace
51 14 Line Markup 20.0% Line Markup $31.80
52 14 Line Markup 20.0% Line Markup $26.80
Estimate Totals Changes
Estimate Type Total Tax Gross Total Customer Responsibility Net Estimate Total Supplement 1 $57.89 $2,924.98 -$500.00 $2,424.98
Supplement 2 $55.56 $2,892.65 -$500.00 $2,392.65
Committed On Version Mitchell Cloud Estimating™ Printed On Profile Page 6 of7 3/3/2025 tchell Estimating 2. 3/3/2025 Mercury
MFEB_25 Copyright 1994-2025 Mitchell International, Inc 11:52 AM Profile Version 11:52 AM All Rights Reserved
8.0 •
CITY OF RIALTO
2025 MAR 1O AM IONgt Estimate Totals
Estimate Type Net Amount
CITY CLERK RECEIVED
Supplement 1 $273.30
Supplement 2 -$32.33
Net Supplement $240.97
Original Estimate $2,151.68
Net Estimate Total $2,392.65
Estimate Type Program Calc Version Data Versions
Supplement 1 14 FEB_25_V
Supplement 2 9 FEB_25_V
Committed On Version Mitchell Cloud Estimating ™M Printed On Profile Page 7 of7 3/3/2025 Mitchell Estimating 24.5 Copyright 1994-2025 Mitchell International, Inc 3/3/2025 Mercury 11:52 AM 11:52 AM Profile Version
All Rights Reserved 8.0
Claim: CAPA-0249917000101 01 MICHAEL GARCIA
ITY OF RIALTO
MAR IO LAMIO: 1
REC ED
CITY ERA
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
2025 MAR 10 AMID: 1
RECEIVED
CITY CLERF
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
2025 MAR 1O AMIO: 11
CEIVED
* CLERE
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
-2075-MAR 10
RECEI
CITY C
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
RIO AMERI
TY
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
AMID: 2
2025 MAR 18
RECEIVED
CITY CLERK
1200
20-
- 220•
3-
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
10 AMIO: 1
CEIVED
CLERK
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
OF RIALTO
15 H R 10
ECEIY
TY CLE
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
PCITY OF RIALTO
2025 MAR 1O AMIO: 12
CITY CLERK RECEIVED
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
2825 MAR 10 AM IO: 12
RECEIVED
CITY CLERK
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Claim: CAPA-0249917000101 01 MICHAEL GARCIA
CITY OF RIALTO
2025 MAR IO
RECEIV
CITY CL
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US POSTAGE
FIRST-CLASS
ZIP 92821 $ 002.59°
CITY OF RIALTO
00080338:8MAR 06 2025
0. Box 10730 Santa Ana, California 92711-073925 MAR 10 AMIO: |0
KELCITLU
CIT Y CLEKK
FIRST CLASS
March 6, 2025
RIALTO CITY CLERK'S OFFICE
150 S PALM AVE
RIALTO, CA 92376
RE: OUR INSURED: MICHAEL