CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
8 CLAIM FOR DAMAGES 2825 MAR 18
AM IO: 41
TO PERSON OR PROPERTY
CITY CLERK RECEIVED
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:
Farmers Insurance Exchange A/S/O Oscar Meza N/A
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: 02/08/2025 TIME: 11:45 X AM O 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.
Lilac Avenue 161 Feet South of Baseline Road
3. HOW DID DAMAGE OR INJURY OCCUR?
Joseph Stauffacher driving a City of Rialto vehicle made an illegal u-turn in front of Oscar Meza.
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.
Joseph Stauffacher driving a City of Rialto vehicle made an illegal u-turn in front of Oscar Meza failing to yield the right of way.
29 04 000075 DZ0535K31 CF0311P1 29[4] 000075
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $6.790.83 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Damages paid by Farmers Amount: $5,290.83
Item/Date: Deductible paid by the insured Amount: $ 1,500.00 :0535PK3
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $6,790.83 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY
Item/Date: Rental Amounts Pending RIALTO
Item/Date: Amount: $. HAR 18 ANTO: 4L
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 61/90.83
CITY CLERK HYED
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: () 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 OP 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 → 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.
CERTIFY JOR DECLARE) UNDERSIAMY SYRFeREBYRYAAT SHAFOREGOING IS TRUE AND CORRECT Brittanv shine Date: 2025.03.10 22:17:21 -04'00'
29 05 000075 DZ0535K31 CF0311P1 29[4] 000075
SIGNATURE OF CLAIMANT OR AGENT
Brittany Shine 03/10/2025
TYPE OR PRINT NAME DATE
Claims Representative
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) :0$35PK3 RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376
CITY OF RIALTO
2025 MAR 18 AMIO: 41
CITY CLERK RECEIVED
29 06 000075 DZ0535K31 CF0311P1 29(4) 000075
CITY OF RIALTO
2025 MAR 18 AMIO: 41
CITY CLERK RECEIVED
Claim Reference Id : 7008638612-1_A5323421
File Name : PHOTO89
File Date : 02/24/2025
Label : Photo 90
Note : Owner:OSCAR LUIS,MEZA|Style:2021,
TOYO,Corolla Hybrid LE w/Continuous
ly Variable Transmission|Insured:OS
29(4] 000075 CAR LUIS,MEZA|LossDate:02/08/2025|P
olicyNumber:0200179467|ShopName:ALL
MAGIC PAINT & BODY FONTANA|Claiman
t:OSCAR LUIS,MEZA| VIN:JTDEAMDE1MJ01
2786|InsuranceCompany: FARMERS INSUR
ANCE EXCHANGE|InsuredisOwner: YEsti
• ALL MAGIC PAINT & BODY FONTANA
29 07 000075 DZ0535PK31 CF0311P1 Photo Location
Photo Taken B • Sole Sanchez
Estimate Indicator
2025 MAR 18 AMIO: 41 CITY OF RIALTO
CITY CLERA RECEIVED
Claim Reference Id : 7008638612-1_A5323421
File Name : PHOTO90
File Date : 02/24/2025
Label : Photo 89
Note : Owner:OSCAR LUIS,MEZA|Style:2021,
TOYO, Corolla Hybrid LE w/Continuous
ly Variable Transmission|Insured:OS
CAR LUIS,MEZA|LossDate: 02/08/2025|P
olicyNumber:0200179467|ShopName:ALL
MAGIC PAINT & BODY FONTANA|Claiman
t:OSCAR LUIS,MEZA|VIN:JTDEAMDE1MJ01
2786|InsuranceCompany: FARMERS INSUR
ANCE EXCHANGE|InsuredisOwner:Y|Esti
29 08 000075 DZ0535K31 CF0311P1 29(4) 000075
ator:Jose,Sanche
LL MAGIC PAINT & BODY FONTAI
: Jose Sanchez
ALL MAGIC PAINT & BODY FONTANA Workfile ID: 6453a865
PartsShare: 8pann6
18150 Foothill Blvd, Fontana, CA 92335 State ID: 264790144-00001 Phone: (909) 434-0500 Federal EPA: PT0040524
FAX: (909) 822-1602 State EPA: CAL000451880
BAR: 296862
Supplement of Record 3 with Summary
RO Number: 4897
Written By: Jose Sanchez, 3/5/2025 8:46:20 AM
Insured: MEZA, OSCAR LUIS Policy #: 0200179467 Claim #: 7008638612-1_A5323421 Type of Loss: COLLI - Collision Date of Loss: 2/8/2025 11:50 AM Days to Repair: 6 Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
MEZA, OSCAR LUIS ALL MAGIC PAINT & BODY FONTANA FARMERS INSURANCE EXCHANGE 18150 Foothill Blvd RIVERSIDE
Fontana, CA 92335 ОКАНО СТУ, О 73126 10) P.O. BOX 268994 Repair Facility
(909) 434-0500 Business (800) 445-7911 Business
VEHICLE
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black VIN: Interior Color: Mileage In: 127,051 Vehicle Out: 3/4/2025 License: Exterior Color: Black Mileage Out:
State: CA Production Date: 8/2020 Condition: Job #: 4897 TRANSMISSION Intermittent Wipers Stereo SEATS
Automatic Transmission Tilt Wheel Search/Seek Cloth Seats POWER Cruise Control Auxiliary Audio Connection Bucket Seats Power Steering Rear Defogger Satellite Radio WHEELS
Power Brakes Keyless Entry Equalizer Wheel Covers
Power Windows Alarm SAFETY PAINT
Power Locks Message Center Drivers Side Air Bag Clear Coat Paint Power Mirrors Steering Wheel Touch Controls Passenger Air Bag OTHER Heated Mirrors Telescopic Wheel Anti-Lock Brakes (4) Traction Control DECOR Climate Control 4 Wheel Disc Brakes Stability Control Dual Mirrors Backup Camera Front Side Impact Air Bags Xenon or L.E.D. Headlamps Tinted Glass Intelligent Cruise Head/Curtain Air Bags California Emissions [4] 000075 Console/Storage RADIO Hands Free Device
CONVENIENCE AM Radio Rear Side Impact Air Bags
29 Air Conditioning FM Radio Lane Departure Warning
000075 DZ0535PK31 CF0311P1
5/2025 8:46:20 AM 428433 Page 1
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black Line Oper Description Part Number Qty Extended Labor Paint Price $
1 FRONT BUMPER & GRILLE
O/H front bumper 3.2
3 **< Repl Non OEM CAPA Bumper cover 52119F2941 1 140.00 Incl. 3.0 4 Add for Clear Coat 1.2
Repl RT Bumper cover clip 9046705170 1 1.72
6 Repl LT Bumper cover clip 9046705170 1 1.72
S02 Repl LT Side retainer 5211602460 1 31.57 0.1
8 R&I RT Outer molding Incl.
9 R&I LT Outer molding Incl.
10 Repl Seal to hood 5339502240 1 61.19 Incl.
11 ** Repl Non OEM CAPA Upper absorber 5261112380 1 41.00 Japan built
12 ** Repl Non OEM CAPA Lower absorber 5261802290 1 42.30 Japan built
13 * S02 Repl USED Impact bar Japan built 5213112310 1 196.00 0.40 (ALU) 17:01
Note: PPI from original quoted vendor
14 ** Repl Non OEM CAPA LT Stay bracket 5701402170 1 175.50 0.3; US built
15 R&I RT Stay bracket US built 0.3
16 ** Repl Non OEM CAPA Lower reinf japan 5213202050 1 97.00 0.4 built (UHS)
17 Repl Trim molding Japan built 5212812920 1 14.02 Inci. 0.3 18 Add for Clear Coat 0.1
19 R&I Upper grille Incl.
20 502 Repl Trim molding Japan built only 5312812050 1 12.58 Note: Missing from accident. Not sold with grille assembly 21 ** Repl Non OEM CAPA Lower grille 5310202280 1 104.55 Incl.
Japan built w/o gloss black
22 R&I License bracket Japan built 0.2
23 Repl Aim distance sensor 1 m 1.6
24 502 Repl RT Bumper cover fastener 4774902020 1 6.03
Note: One time use
25 S02 Repl LT Bumper cover fastener 4774902020 1 6.03
Note: One itme use
26 FRONT LAMPS
27 * S02 Repl USED RT Headlamp assy 8114512L80 1 840.00 0.5 w/accent lighting +20%
Note: AMERICAN DISMANTLING NA#120862
Per parts trader, suppliers could not provide proper part 28 * Repl USED LT Headlamp assy 8118512L80 1 714.00 0.5 29 10 000075 DZ0535PK31 CF0311P1 29 (4) 000075 w/accent lighting +20% Note: BENZ NA#6374SIMONA
29 Repl Aim headlamps 1 0.5
5/2025 8:46:20 AM 428433 Page 2
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black 30 RADIATOR SUPPORT
31 ** S02 Repl Non OEM CAPA Under cover 5145112120 1 182.00 0.3 Note: PPI from original vendor
32 Repl Under cover clip 9046707220 3 5.79
33 ** Repl Non OEM CAPA LT Side shield 5144402100 1 36.55 0.3 34 ** Repl Non OEM KEYSIQ Rear shield 5141012181 1 182.00 0.4 35 R&I Sight shield Incl.
36 FENDER
37 * Algn LT Fender
* Rpr LTFender E,20
38 39 Overlap Major Non-Adj. Panel 40.2
40 Add for Clear Coat 9,4
18 41 # Basecoat Reduction -0,7
42 ** Repl Non OEM CAPA LT Fender liner 5380612100 100.80 Japan built L, LE, Hybrid LE
43 R&I LT Corner trim Japan built black
44 ** Repl Non OEM LT Front brace 5383602020 1 27.53 0.7 45 Add for Clear Coat 0.1
46 Rpr LT Apron assy (HSS) 0.5' 2.5
47 WHEELS
48 * S02 Rep| USED LT/Front Wheel, alloy 15" 4261147450 1 172.80 m 0.1 +20%
49 * 502 Repl LT/Front Wheel cover 15" alloy 4260247261 1 115.92 wheel
50 TIRES
51 * 503 Repl MICH 195/60R15 Defender T+H MI09605 1 182.34 Incl BW 88H B20%
Note: Tire Betterment applied at 20% 8 old tire thread out of 10 New Tire Thread. 52 # S02 Subl CA tire fee 1 1.75 X
# 502 Subl Tire disposal fee 1 4.40 X
54 VEHICLE DIAGNOSTICS
55 * 502 Subl Pre-repair scan 1 60.00 xm
56 * S02 Subl Post-repair scan 1 60.00 Xm
57 * Subl Reset and clear all active DC'S 1 156.00 Xm
58 * 502 Subl Calibrate front radar sensor 1 531.00 Xm
59 * 502 Subl Calibrate occupant classification 1 331.00 Xm system
g # So2 Subl Max sublet mark up 1 200.00 X
61 MISCELLANEOUS OPERATIONS
62 # Repl Cover car for Overspray 1 5.00 X 0.2
63 # Cover Car for Primer 1 2.00 X 0.1
64 # Flex Additive 1 3.00 T
65 # Corrosion Protection -*** 1 5.00 T
66 # Color Tint 1 0.5
# Subl Tire Mount & Balance 1 12.00 X
68 # Tire Disposal Fee 1 4.00 X
5/2025 8:46:20 AM 428433 Page 3
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black 69 # D&R Battery 1 0.1
70 # De-Nib and Polish 0.3
71 Adhesion Promoter 1 5.00
72 # 502 Valve Stem 1 9.07 X
73 # D&R wiring harness 1
74# Subl Four wheel alignment 1 79.95 X 200 of
75# Repl Electrical/wiring/harness Masking 1 2.00 X
RIALT
76 OTHER CHARGES
77 # E.P.C. 1 3.00
SUBTOTALS 4,965.11 14.4 F7.5
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 3,495.94
Body Labor 14.4 hrs @ $ 58.00/hr 835.20
Paint Labor 7.5 hrs @ $ 58.00/hr 435.00
Paint Supplies 7.5 hrs @ $40.00/hr 300.00
Miscellaneous 1,466.17
Other Charges 3.00
Subtotal 6,535.31
Sales Tax $ 3,803.94 @ 7.7500 % 294.81
Grand Total 6,830.12
Deductible 1,500.00
MICH 195/60R15 Defender T+H BW 88H 39.29
B20%
CUSTOMER PAY 1,539.29
INSURANCE PAY 5,290.83
5/2025 8:46:20 AM 428433 Page 4
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Changed Items
51 S02 Repl MICH 195/60R15 Defender T+H MI09605 1 -182.34 Incl BW 88H B20%
* S03 Rep| MICH 195/60R15 Defender T+H MI09605 1 182,34 Incl BW 88H B20%
NOTE: Tire Betterment applied at 20% 8 old tire thread out of 10 New Tire Thread.
SUBTOTALS 0.00 0.0 0.0
TOTALS SUMMARY
Category Basis Rate Cost $
Parts 0.00
Subtotal 0.00
MAR 18
CUMULATIVE EFFECTS OF SUPPLEMENTS) RECEIV
Y OF RIALTO
Estimate 5,078.22 Jose Sanchez
Supplement S01 CLERK ED
-11.60 Jose Sanchez AMI0: 41
Supplement S02 1,763.50 Jose Sanchez
Supplement S03 0.00 Jose Sanchez
Job Total: $ 6,830.12
CUSTOMER PAY: $ 1,539.29
INSURANCE PAY: $ 5,290.83
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 '5/2025 8:46:20 AM 428433 Page 5
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black INCURRED DURING REPAIRS.
THANK YOU FOR CHOOSING THE GUARANTEED REPAIR PROGRAM
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 AR OF
WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. co
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 F 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 Any concerns regarding how an auto insurance claim is being handled should be submitted to the California '5/2025 8:46:20 AM 428433 Page 6
749 Page 13 of 28
Supplement of Record 3 with Summary
-O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black Department of Insurance at:
(800) 927-HELP or (213) 897-8921
California Department of Insurance
Consumer Services Division
300 South Spring Street, SOUTH TOWER
Los Angeles, CA 90013
The California Department of Insurance can also accept complaints over its website at: www.insurance.ca.gov.? We must be notified by the repair facility, and physically inspect, all requests for supplemental damage. Failyre fo provide adequate notice may result in nonpayment of additional charges not contained in this appraisal. 81 CITY OF RIALTO
AM IO: 41
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS FALSE
OR FRAUDULENT INFORMATION TO OBTAIN OR AMEND INSURANCE
COVERAGE OR TO MAKE A CLAIM FOR THE PAYMENT OF A LOSS IS
GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY
BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:
MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART,
A=APPROXIMATE PRICE. LABOR TYPES: B=BODY LABOR, D=DIAGNOSTIC, E=ELECTRICAL, F=FRAME, G=GLASS, M=MECHANICAL, P=PAINT LABOR, S=STRUCTURAL, T=TAXED MISCELLANEOUS, X=NON TAXED
MISCELLANEOUS. CCC ONE: ADJ=ADJACENT, ALGN =ALIGN,
A/M=AFTERMARKET, BLND=BLEND, CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT,
EST=ESTIMATE, EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED, MISC=MISCELLANEOUS, NAGS=NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ=NON ADJACENT, O/H=OVERHAUL,
OP=OPERATION, NO=LINE NUMBER, QTY=QUANTITY,
RECOND=RECONDITION, REFN=REFINISH, REPL=REPLACE, R&I=REMOVE AND INSTALL, R&R=REMOVE AND REPLACE, RPR=REPAIR, RT=RIGHT, SECT=SECTION, SUBL=SUBLET, LT=LEFT, W/O=WITHOUT, W/_=WITH/_ SYMBOLS: #=MANUAL LINE ENTRY, *=OTHER [IE.MOTORS DATABASE INFORMATION WAS CHANGED], **=DATABASE LINE WITH AFTERMARKET, N=NOTES ATTACHED TO LINE. OPT OEM=ORIGINAL EQUIPMENT
29 15 000075 DZ0535K31 CF0311P1 29[4] 000075 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 5/20258:46:20 AM 428433 Page 7
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black
MANUFACTURER, THE WINDSHIELD ADHESIVE NEEDS TO CURE UNTIL THE
WINDSHIELD CAN PROPERLY FUNCTION AS A SAFETY DEVICE PURSUANT
TO THE FEDERAL MOTOR VEHICLE SAFETY STANDARDS AND THE
VEHICLE MANUFACTURER'S SPECIFICATIONS.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS
ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE.
"If the above estimate includes a NAPA part price, the repair facility must complete a one time set up with their local NAPA retailer in order to receive the special "Farmers Preferred Parts Program" pricing. To accomplish set up, contact your local NAPA retailer and ask them to insert billing code number 9066 into your customer billing profile.
The 9066 code will enable your repair facility to receive special pricing on all NAPA parts and/or supplies purchased.
If you do not already have a local NAPA retailer account, please call 1-800 LET-NAPA for your nearest NAPA location." EVERY MAR 18 AMIO:42 CITY OF RIALTO
5/2025 8:46:20 AM 428433 Page 8
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black 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 ARM8434, CCC Data Date 02/17/2025, 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 update CITY 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 deatership.-. OF The following is a list of additional abbreviations or symbols that may be used to describe work to be done of parts to be repaired or replaced: RIALTO
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 Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. '5/2025 8:46:20 AM 428433 Page 9
Supplement of Record 3 with Summary
-O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI 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 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 THE PROBLEM IS CORRECTED. CITY
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 OF REPAIR. FOR ASSISTANCE, PLEASE CONTACT YOUR INSURANCE COMPANY'S NEAREST CLAIM DEPARTMENT OFFICE. RIALTO
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. 5/2025 8:46:20 AM 428433 Page 10
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black
PARTS SUPPLIER LIST
Line Supplier Description Price
3 iPart Automotive #AM5366 $140.00
14975 hilton driver Non OEM CAPA Bumper cover
Fontana CA 92335 Quote: 3477968961
(909) 587-6059 Expires: 02/24/25
41:00
11 Keystone, Inc #T01070235C
15895 VALLEY BLVD, SUITE 100 Non OEM CAPA Upper absorber Japan built MAR FONTANA CA 92335 Quote: 2865309054 2,70
(800) 421-7866 Expires: 04/03/25
National Auto Parts - San Diego #TY35AB041C
8701 Siempre Viva Rd Non OEM CAPA Lower absorber Japan built San Diego CA 92154 Quote: 3479460693
(619) 661-6883 Expires: 02/24/25
13 Cherry Auto Parts #P967 $70.00
11911 SHELDON ST USED Impact bar Japan built (ALU)
Sun Valley CA 91352 BUMPER REINF FRONT-INSURANCE QUALITY 1PC LOWER,S#P967 (818) 767-0047 Quote: 3476472747
Expires: 03/19/25
14 National Auto Parts - San Diego #TY35BB058C $ 175.50 8701 Siempre Viva Rd Non OEM CAPA LT Stay bracket US built San Diego CA 92154 Quote: 3477572844
(619) 661-6883 Expires: 02/24/25
16 Keystone, Inc #T01007112C $97.00
15895 VALLEY BLVD, SUITE 100 Non OEM CAPA Lower reinf japan built (UHS) FONTANA CA 92335 Quote: 2865309594
(800) 421-7866 Expires: 04/03/25
21 National Auto Parts - San Diego #TY35B1065C $104.55
8701 Siempre Viva Rd Non OEM CAPA Lower grille Japan built w/o gloss black San Diego CA 92154 Quote: 3478364583
(619) 661-6883 Expires: 02/24/25
[4] 000075 27 ALL STAR AUTO PARTS CA #080204 $595.00
SALES TEAM USED RT Headlamp assy w/accent lighting +20% 3870 GARNER RD H/Lamp Assy, Rt RT H/LAMP
ASSY-RH,LED, COMP,PRO100,S#08020425
RIVERSIDE CA 92501
(407) 271-8949
29 19 000075 DZ0535PK31 CF0311P1
28 ALLIED AUTO SALVAGE - TEAM PRP #001515 $300.00
SALES NUMBER USED LT Headlamp assy w/accent lighting +20% 5/2025 8:46:20 AM 428433 Page 11
Supplement of Record 3 with Summary
O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black 1926 SPRUCE STREET H/Lamp Assy, Lt LT H/LAMP ASSY-NONE,S#00151537 RIVERSIDE CA 92507
(951) 784-0057
31 National Auto Parts - San Diego #TY35EC051C $182.00
8701 Siempre Viva Rd Non OEM CAPA Under cover
San Diego CA 92154 Quote: 3480252031
(619) 661-6883 Expires: 02/24/25
33 National Auto Parts - San Diego #TY35EC056C
8701 Siempre Viva Rd Non OEM CAPA LT Side shield
San Diego CA 92154 Quote: 3472591743
(619) 661-6883 Expires: 02/24/25
34 Keystone, Inc #TO1228262
15895 VALLEY BLVD, SUITE 100 Non OEM KEYSIQ Rear shield FONTANA CA 92335 Quote: 2865318372
(800) 421-7866 Expires: 04/03/25
42 National Auto Parts - San Diego #TY35FR030C $ 100.80 8701 Siempre Viva Rd Non OEM CAPA LT Fender liner Japan built L, LE, Hybrid LE San Diego CA 92154 Quote: 3474171321
(619) 661-6883 Expires: 02/24/25
44 National Auto Parts - San Diego #TY35FK004 $27.53
8701 Siempre Viva Rd Non OEM LT Front brace
San Diego CA 92154 Quote: 3479660140
(619) 661-6883 Expires: 02/24/25
48 AMERICAN DISMANTLING INC. #8907 $75.00
SALES NUMBER USED LT/Front Wheel, alloy 15" +20%
15303 ARROW BLVD Wheel WHEEL-16",S#8907
FONTANA CA 92335
(800) 527-2739
29 20 000075 DZ0535K31 CF0311P1 29[4] 000075
5/2025 8:46:20 AM 428433 Page 12
Supplement of Record 3 with Summary
..O Number: 4897
2021 TOYO Corolla Hybrid LE w/Continuously Variable Transmission 4D SED 4-1.8L Hybrid Sequential MPI Black
TIRE PARTS SUPPLIERS
Line Description Supplier Price
51 MICH 195/60R15 Defender T+H BW 88H Big O $182.34
B20%
1002 W 6TH STREET, CORONA CA 92882-0 (951) 735-2430
те мет на.
29 21 000075 DZ0535PK31 CF0311P1 29[4] 000075
'5/2025 8:46:20 AM 428433 Page 13
TE OF CALIFORNIA
ARTMENT OF CALIFORNIA HIGHWAY PATROL
RAFFIC CRASH REPORT
P 555 Page 1 (Rev. 2-22) OP| 060 Page 1 of 8
IAL CONDITIONS HIT & RUN CITY JUDICIAL DISTRICT | LOCAL REPORT NUMBER PENDE
COURTESY REPORT RIALTO FONTANA COURTHOUSE 9860-2025-00403
ON-DUTY EMERGENCY VEHICLE
COUNTY REPORTING DISTRICT BEAT DAY OF WEEK TOW AWAY
KILLED MISDEMEANOR
SAN BERNARDINO SMT W TES DYES XINO
CRASH OCCURRED ON CRASH DATE CRASH TIME (2400) NOTIF. TIME (2100) NOC# OFFICER ID MO. YEAR
LILAC AVENUE 02/07/2025 1145 02/07/2025 1155
STATE HAY REL DIGITAL MEDIA
AT INTERSECTION WITH 50 YES
X OR: 161 FEET SOUTH of BASELINE ROAD •YESX] NO DNO EMBEDDED
LOCATION I SAME AS LOCATION
COPE COORDINATES FOR LOGATION DO, AND ARENA OFIMPACT ROT LAT. LONG, 22 LAR, REFERTO NARATiVE LONE
34.120763 -117.379216 34.120763 -117.379216
AGIT LAT. LONG. LONG. LAT. LONG.
3 A4T AT.
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKEMODELGOLOR LICENSE NUMBER STATE CA M G 2020 FORD EXPLORER BLK/WHI CA
DRIVER NAME (FIRST, MIDDLE, LAST) ON-DUTY EMERGENCY VCHICLE
JOSEPH JOHNPAUL STAUFFACHER OMNERS NAME SAME AS DRIVER
PEDES- STREET ADDRESS CITY OF RIALTO
TRIAN
128 NORTH WILLOW AVENUE OWNERS ADDRESS SAME AS DRIVER
PARKED | CiTY/STATE/ZiP 249 SOUTH WILLOW AVENUE RIALTO CA 92376
VEHICLE
RIALTO CA 92376 DISPOSTTION OF VEHICLE ON ORDERE OF: OFFICER I DRIVER OTHER BICY- SEX HAIR TEYES [HEIGHT TWEIGHT MIRTHDATE Your RACE DRIVEN AWAY M BRN BRN 's'10' 220 PRIOR MECHANICAL DEFLOYS: X NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
UNKNOWN (909) 820-2550 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE OPER* INSURANCE OARRIER POLICY NUMBER LUNK. ] NONE MINOR AToR 48 MAJOR ROLL-OVER
CITY OF RIALTO SELF INSURED [X MOD.
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL EPEED
LANES LANES UMIT DOT.
TRAVEL
N LILAC AVENUE N/B 1 40 CAL-T TOPIP60. MC/MX.
STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE
PARTY DRIVER'S CENSE NUNDER
2 CA M G 2021 TOYT COROLLA BLK CA
DRIVER NAME (FIRST, MIDDLE, LAST)
OSCAR LUIS MEZA JR WANER'S NAME XI SAME AS DRIVER
PEDES- STREET ADDRESS 2x 87
THAN OWNER'S ADDRESS X SAME AS DRIVER 18
PARKED CITY/STATE/ZIP
VEHCLE All.
RIALTO CA 92377 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER
XORIVER SOOTHER
BICY- SEX THAIR [EYES THEIGHT TWEIGHT Me BIRTHDATE Your RACE DRIVEN AWAY GUST M BLK BRN 5'9" 180 H PRIOR MECHANIOAL DEFECTS: X NONE APPARENT PREFER TONSRRATWIS OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DANAGE TORYNE
OPER POLICY NUMBER • UNK. NOWE MINOR
INSURANCE CARRER
ATOR FARMERS INSURANCE 200179467 01 MAJOR ROLL-OVER
LANE T THAL TAPEED
DIR OF ON STREET OR HIGHWAY LANES LIMIT CA DOT
LILAC AVENUE S/B 40 CAL-T TOPPAC
STATE CLASS AIR BAG SAFETY, EQUIP. VEH. YEAR MAKE/MODEL/COL.OR LICENSE NUMBER STATE
PARTY DRIVER'S LICENSE NUMBER
3 DRIVER NAME (FIRST, MIDDLE, LAST)
• OWNER'S NAME SAME ASDRIVER
PEDES- STREET ADDRESS
TRIN
OVINER'S ADDRESS I SAME AS DRIVER
PARKED CITY/STATEZIP
VE-CLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER OTHER
SEX THAIR EYES HEIGHT TWEIGHT RACE
CUST
29 22 000075 DZ0535K31 CF0311P1 29[4] 000075 PRIOR MECHANICAL DEFECTS: NONE APPARENT • REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFIGATION NUMBER:
VEHICLE TYPE DESORBE VEHICLE DAMAGE
OPER- POLICY NUMBER •UNK. •NONE MINOR
INSURANCE CARRIER
•MOD. •MAJOR ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
LANES LANES CA DOT.
TRAVEL LIMIT
GAL-T TOP/PSC
ARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME CATE REVIEWED I K RAY, 022553 •YES •NO NIA
Iterationally Accredited Agency
TE OF CALIFORNIA
'ARTMENT OF CALIFORNIA HIGHWAY PATROL
RAFFIC CRASH CODING of ฿
Pago 2
:P 555 Page 2 (Rev. 2-22) OPI 060
..SH DATE (MO. DAY YEAR) CRASH TIME (2400) OFFICER ID NUMBER 02/07/2025 1145 9860-2025-00403
PROPERTY OWNER'S NAME OWNER'S ADDRESS
DAMAGE
PERSON NOTIFIED I SAME AS OWNER TELEPHONE NUMBER METHOD OF NOTIFICATION (MARK ALL THAT APPLY) LOG/ INCIDENT NUMBER TIN PERSON PHONE DISPATCH ]CHP 422
DESCRIPTION OF DAMAGE
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES
OCCUPANTS CHILD RESTRAINT B - UNKNOWN A - CELLPHONE HANDHELD
A - NONE IN VEHICLE L - AIR BAG DEPLOYED
Q - IN VEHICLE USED M - AIR BAG NOT DEPLOYED B - CELLPHONE HANDSFREE 1 TO 9- STANDARD SEATING B - UNKNOWN R - IN VEHICLE NOT USED C - ELECTRONIC EQUIPMENT
POSITION C - LAP BELT USED N- OTHER
S- IN VEHICLE USE UNOWN P - NOT REQUIRED D - RADIO / CD ) - LAP BELT NOT USED E - SMOKING
E - SHOULDER HARNESS USED T - IN VEHICLE MAPROPER USE
1 2 3 10 - REAR OCC, TRK., VAN, U - NONE IN VEHICLE F-EATING STATION WAGON, ETC.* F - SHOULDER HARNESS NOT USED EJECTED FROM VEHICLE
G- LAPISHOULDER HARNESS USED G-CHEDREN
4 5 6 MICHICYCLE-HELMET O - NOT EJECTED
H- LAP/SHOULDER HARNESS NOT USED 1 - FULLY EJECTED H- ANIMALS 11 - POSITION UNKNOWN* DRIVER PASSENGER 1- PERSONAL HYGIENE 789 J- PASSIVE RESTRAINT USED V - NO X-NO 2 - PARTIALLY EJECTED K- PASSIVE RESTRAINT NOT USED 3 - UNKNOWN J- READING
10 0 - OTHER* W- YES Y - YES K- OTHER
P- NOT REQUIRED
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY CRASH FACTOR TRAFFIC CONTROL DEVICES 1 2 VEHICLE AUTOMATION LEVEL MOVEMENT PRECEDING CRASH LIST NUMBER (#) OF PARTY AT FAULT
CITED A CONTROLS FUNCTONING A SAE LEVEL - 0 A SCORPED
VC 21801(a) B CONTROLS NOT FUNCTIONING* B SAE LEVEL. - 1 X B PHOCEEDING STRAIGHT KING
g OTHER IMPROPER DRIVING*: C CONTROLS OBSCURED C SAE LEVEL - 2 CRANIOFE ROADA X D NO CONTROLS PRESENT / FACTOR* D SAE LEVEL - 3 ID MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF CRASH E SAE LEVEL - 4 E MAKING LEFT YUAN, D UNKNOWN* A HEAD - ON F SAE LEVEL - 5 X IF MAKING U TURN B SIDE SWIPE G UNKNOWN* G BACKING
C REAR END IH SLOWING / STOPPING
1 2 VEHICLE AUTOMATION ENGAGED -
WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE PASSING OTHER VEHICLE
A CLEAR E HIT OBJECT X A NO AUTOMATION J CHANGING LANES
B CLOUDY F OVERTURNED B DRIVER ASSISTANCE K PARKING MANEUVER
C RAINING G VEHICLE / PEDESTRIAN C PARTIAL AUTOMATION ENTERING TRAFFIC D SNOWING H OTHER*: D CONDITIONAL AUTOMATION M OTHER UNSAFETURNING E FOG/ VISIBILITY FI._ MOTOR VEHICLE INVOLVED WITH E HIGH AUTOMATION IN XING INTO OPPOSING LANE F OTHER* (MARK 1 TO 2 ITEMS) F FULL AUTOMATION O PARKED G WIND A NONCOLLISION G UNKNOWN* P MERGING
LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY
X A DAYLIGHT X C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS) R OTHER*:
2 (MARK 1 TO 2 ITEMS)
B DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY S LANE SPLITTING C DARK - STREET LIGHTS E PARKED MOTOR VEHICLE A OVO SECTION VIOLATION: SOBRIETY • DRUG - PHYSICAL -YES 2 3
D DARK - NO STREET LIGHTS F TRAIN I NO (MARK ALL THAT APPLY) E DARK - STREET LIGHTS NOT G BICYCLE OVO ULOTION VIOLAICH: X A HAD NOT BEEN DRINKING FUNCTIONING* H ANIMAL: B HBD-UNDER INFLUENCE
I FIXED OBJECT: CUC BECTION VIOLATICH: OTED YES C HBD - NOT UNDER INFLUENCE*
ROADWAY SURFACE C
X A DRY D MBD - IMPAIRMENT UNKNOWN*
B WET J OTHER OBJECT: D E UNDER DRUG INFLUENCE*:
C SNOWY - ICY E VISION OBSCUREMENT: DRE EXAM. CONDUCTED D SLIPPERY (MUDDY, OILY, ETC.) K ADDITIONAL OBJECTS) STRUCK F INATTENTION®: STIMULANT
ROADWAY CONDITION(S) PEDESTRIAN'S ACTIONS G STOP & GO TRAFFIC HALLUCINOGEN (MARK 1 TO 2 ITEMS) X A NO PEDESTRIANS INVOLVED H ENTERING / LEAVING RAMP DISSOCIATIVE ANESTHETICS LA HOLES, DEEP RUT* B CROSSING IN CROSSWALK | PREVIOUS CRASH NARCOTIC ANALGESIC B LOOSE MATERIAL ON ROADWAY* AT INTERSECTION J UNFAMILIAR WITH ROAD INHALANT C OESTRUCTION ON ROADWAY" CANTERGENTSWALK-NOT K DEFECTIVE VEH. EQUIP OM] YES CANNABIS
D CONSTRUCTION - REPAIR ZONE DEPRESSANT
E REDUCED ROADWAY WIDTH L UNINVOLVED VEHICLE F IMPAIRMENT -PHYSICAL* F FLOODED* M OTHER: G IMPAIRMENT NOT KNOWN
G OTHER*: F NOT IN ROAD N NONE APPARENT • H NOT APPLICABLE XH NO UNUSUAL CONDITIONS G APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE SLEEPY / FATIGUED*
MISCELLANBOUS
1 2 3 SPECIAL INFORMATION
REFER TO SKETCH PAGES) A HAZARDOUS MATERIAL
INDICATE NORTH B CELL PHONE HANDHELD IN USE
C CELL PHONE HANDSFREE IN
USE
D CELL PHONE NOT IN USE
E CELL PHONE USE UNKNOWN
IF SCHOOL BUS RELATED
1 2 3 BIKEWAY FACILITY
A SHARED ROADWAY
B CLASS I - BIKE PATH*
C CLASS II - BIKE LANE*
D CLASS II - BIKE ROUTE*
E CLASS IV - SEPARATED
•REFER TO NARRATIVE FOR ADDITIONAL INFORGATION BIKEWAY* Iterationally Accredited Agency
CASE Page 22 of 28
F CALIFORNIA HIGHWAY PATRO
JURED / WITNESS / PASSENGERS Page 3 of 8
P 555 Page 3 (Rev. 2-22) OPI 060
3H PATE (MO. DAY YEAR) CRASH TIME (2400) NCIC # OFFICER ID NUMBER 02/07/2025 1145 9860-2025-00403
EXTENT OF INJURY ("X" ONE) INJURED WAS ('X" ONE) PARTY SEAT, AR
WITNESS PASSENGER SEX SAFETY EJECTED
ONLY ONLY AGE FATAL NUMBER POS. BAG EQUIP.
DRIVER PASS, PED. BICYCLIST OTHER OPER.
INJURY INJURY INJURY
7# 8 F L
NAME / D. O, B. / ADRESS TELEPHONE
ZOEY DOROTHY MEZA (01/08/2017) 2487 POWELL DRIVE RIALTO CA 92377 NONE/NONE (INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
7#
NAME / D. O. B. / ADDRESS EJRLEPHONE
(INJURED ONLY) TRANBPORTED BY: EMS RUN NUMBER: TAKEN TO:
DESCRIBE INJURIES
20 NAME / D. O, B. / ADDRESS TELEPHONE
INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
NAME / D. O. B. / ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER: TAKEN TO;
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
NAME / D. O. B./ ADDRESS TELEPHONE
ULRED ONLY) TRANSPORTED BY: EMS RUN NUMBER: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
#
NAME / D. O. B. / ADDRESS TELEPHONE
29 24 000075 DZ0535PK31 CF0311P1 29[4] 000075
(INJURED ONLY) TRANSPORTED BY: EMS RUN NUMBER: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
ARER'S NAME ID NUMBER MO. DAY YEAR REVIEWER'S NAME IMO. DAY YEAR I KRAY 022553 02/07/2025
An IntPage 23 of 28 .. lgency
DEPARTE AT DO BALDANA HIGHAY PATROL
SKETCH DIAGRAM
CHP 595 Page 4 (Rev. 2-22) OP1 050 Pegs: 4 ofs
CRAM DATE (MO. SHASH TIME CAR [OFFICER D NUNSER
02/07/2025 1145 9860-2025-00403
ALL MEASUREMENTS ARE APPROXHRATE AND NOT TO SCALE UNLESS STATED (SCALE:
W
- N
LILAC AVENUE E
2025 MAR 18 CITY OF RI
SOUTH V-2
12% BOUND 404
LEFT TURN
ONLY
24 NORTH V-1
BOUND
BASELINE ROAD
LEGEND:
A: Solid painted white line:
B:Raised concrete sidewalk
C:Painted double yellow line
29[4] 000075
CF0311P1
000075 DZ0535PK31
PREPARED ar TOMATER MO: DAY TEAR REVIESER'S HASTE TMO. DAY YEAR AMIK RAY 022553 02/07/2025
An Internationally Accredited Agancy Page 24 of 28
STATE OF CALIFORNIA
NARRATIVE SUPPLEMENTAL PAGE 5 OF 8
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
02/07/2025 1145 9860-2025-00403
1 All times, speeds, and measurements throughout this report are approximate. Measurements were obtained using 2 visual estimation and GPS unless otherwise stated. All opinions and conclusions were based on evidence and/or 3 statements.
5 OTHER FACTUAL INFORMATION
6 7 Party #1 (P1, Stauffacher) at the time of the crash was on duty as a sworn peace officer with the Rialto 8 Police Department as defined in Chapter 4.5 commencing with section 830, Part 2, and Title 3 of the?. 9 California Penal Code and was operating an authorized emergency vehicle as described in Subdiyision. (a), 10 (b), or (f) of California Vehicle Code Section 165.
11 12 STATEMENTS
13 14 Party #1 (P1, Stauffacher) was contacted in a parking lot on the southeast corner of Lilac Avenue at 15 Baseline Road and related in essence the following: He was driving Vehicle #1 (V1, Ford) northbound on 16 Lilac Avenue, south of Baseline Road in the northbound lane slowing to a speed of approximately 3 mph. 17 He said he was slowing and began to make a U-turn to proceed southbound on Lilac Avenue: As he 18 conducted the U-turn, he felt an impact to the right front of his vehicle from an approaching southbound 19 vehicle. After the crash, he contacted the other driver and relocated his vehicle to the parking lot on the 20 southeast comer of Lilac Avenue and Baseline Road where he waited with his vehicle for CHP arrival. 21 22 Party #2 (P2, Meza) was contacted in a parking lot on the southeast corner of Lilac Avenue at Baseline 23 Road and related in essence the following: He was driving Vehicle #2 (V2, Toyota) southbound on Lilac 24 Avenue, north of Baseline Road, in the southbound lane, at approximately 25 mph. He was accelerating 25 through the intersection and observed a vehicle in the northbound lane waiting to make a left turn to 26 proceed westbound on Baseline Road with other vehicles waiting in the northbound lane behind it. As he 27 proceeded southbound on Lilac Avenue, south of Baseline Road, he observed the patrol vehicle enter the 28 southbound lane ahead of him and it appeared he was attempting to make a U-turn. When he observed 29 the vehicle in the southbound lane ahead of him, he applied the brakes to his vehicle, but he was unable to 30 stop in time. As a result, the front of his vehicle collided with the right front of the patrol vehicle. After the 31 crash, he relocated his vehicle to the parking lot on the southeast corner of Lilac Avenue and Baseline 32 Road where he waited with his vehicle for CHP arrival. 33 PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE
AMI K RAY 022553 02/07/2025
-Page 25 of 28
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 6 OF 8
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
02/07/2025 1145 9860-2025-00403
1 SUMMARY/CAUSE
2 3 Party #1 (P1, Stauffacher) was driving Vehicle #1 (V1, Ford) northbound on Lilac Avenue, south of 4 Baseline Road, in the northbound lane, and was slowing to approximately 3 mph. Party #2 (P2, Meza) 5 was driving Vehicle #2 (V2, Toyota) southbound on Lilac Avenue, south of Baseline Road, in the 6 southbound lane at a stated 25 mph. This crash occurred when Party #1 made a U-turn in the direct path 7 of Vehicle #2 and failed to yield the right-of-way of Vehicle #2 (Violation of 21801(a) California Vehicle 8 Code). Party #1 entered the southbound lane in the direct path of Vehicle #2. Party #2 observed Vehicle 9 #1 directly ahead and applied the brakes to Vehicle #2 but was unable to stop in time. As a result, the front 10 of Vehicle #2 collided with the right front of Vehicle #1 (Area of Impact). After the crash, bolf parties 11 relocated their vehicles to the parking lot on the southeast corner of Lilac Avenue and Baseline Road 12 where they waited for CHP arrival. 18
CLERK EIVED AM IO: 42 OF RIALTO
PREPARED BY T.D. NUMBER DATE REVIEWER'S NAME DATE
AMI K RAY 022553 02/07/2025
- Page 26 of 28
ANE OF CALIPORNIA
EPARTMENT OF CALFORNIO HICHMAY PATROL
PHOTOS
CHP 555 OPI 060 Page 8
DATE OF GHẠSH MỌ. DAS YEARS TIASE 12400) NGC R OFFICER 10 02/07/2025 1145 9860-2025-00403
TOYOTA 2 TOYOTA 3
CAPY CLERK RECEI 1025 MAR 18 AM IO: 42 CITY OF RIALTO
TOYOTA 4
8267
PREPARED BY ID NUMPER NO. DAY YEAR BEEMER'S NAME TROL AY YEAR AMIKRAY 022553 02/07/2025
i internationally Accredited Agency "Page 27 of 28
Toll Free: (800) 435-7764
Email: [email protected]
FARMERS Please include your claim # оп any correspondence INSURANCE National Document Center
00. homa Gry, 0K 73126-89917
March 11, 2025
www.farmes.com/claimstatus
Payment Log
Account Number: JJJ3S1481
Date of Loss: 02/08/2025
Insured's Name OSCAR LUIS MEZA
Claim Number: 7008638612-1
Unit Type Claim Unit Date Issued Payee Check Number Payment 55,.9u3
Vehicle 03/06/2025 CALL MAGIC PAINT & BODY INC. - 1641945980
FONTANA
Payment Total: $5,290.83
Collections Total : $0.00
Deductible: $0.00
Grand Total : $5,290.83
CLERK 2025 MAR 18 AMIO: 42 CITY OF RIALTO
ED
DZ0535PK3 Page 28 of 28
2825 MAR 18 CITY OF RIALTO
Toll Free: (800) 435-7364
FARMERS National Document CerT Y CLERK EIVED
•P.O. Bot 268992
INSURANCE Oklahoma City. OK. 73126-8992
Fax: (877) 217-1389
03/10/2025
City Of Rialto
Attention: City Clerk's Office
150 S Palm Avenue
Rialto, CA 92376
Our Insured: Oscar Luis Meza
Our Claim #: 099 SUB 7008638612-1
Date of Loss: 02/08/2025
Your Insured: Responsible Party Unknown
Your Claim #:
Deductible Amount: $1,500.00
Total Amount Owed: $6,790.83
Dear City Of Rialto - Attention: City Clerk's 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 $6,790.83.
Our theory of liability is as follows: Joseph Stauffacher driving a City of Rialto vehicle made an illegal u-turn in front of Oscar Meza. The accident occurred on Lilac Avenue 161 Feet South of Baseline Road.
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 000075 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.
DZ0535PK31 CF03*
If you need additional support for our claim or require further information, please contact me. Please send payment to:
000075
National Document Center
PO Box 268992
Oklahoma City, Ok 73126
:0535PK3
Thank you,
Brittany Shine CITY OF RIALTO
Litigation Claims Representative 2025 MAR 18 AMIO: 41
Farmers Insurance Exchange
616-803-7653 RECEIVED
CITY CLERK
29 03 000075 DZ0535PK31 CF0311P1 29(4] 000075
FIPST
U.S F
FARMERS
INSURANCE
National Document Center
From: PO. Box 268994
Oklahoma City, OK 73126-8994
000075
FIRST CLASS MAIL CONFIDENTIAL
CITY OF RIALTO 2025 MAR 18 AMIO: 40 RECEIYEL CITY CLERK
SELF INSURED
150 S PALM AVENUE
RIALTO CA 92376
62 5.1 CAABNFE 92376