CITY CLERK'S DATE STAMP
CITY OF RIALTO
SA HO CATO
LIABILITY
CLAIM FOR DAMAGES JUN 13 CITY OF RIA
TO PERSON OR PROPERTY
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 9237( iddress: 290 W. Rialto Ave., Rialto, CA 9237
CLAIMANT INFORMATION:
Farmers Insurance Exchange a/s/o Omar Torres N/A
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
P.O. Box 268994, OK City, OK 73126 (616,803-7667
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
Jeanette Hild c/o Farmers Insurance Exchange
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM Claim# 7008971716-1. P.O. Box 268994, OK City, OK 73126 (if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 5-13-2025 2:36pm TIME: DAM F 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.
Baseline and Riverisde, Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
On 5-13-2025 at appx 2:36pm on Baseline and Riverside, CA, Courtney Lynn driving City of Rialto PD veh at time of loss hit the insured driver Rianna orres as insured was pulling back out into traffic from pulling over prior for a police officer going by with sirens on. Officer Lynn did not have sirens on when passing
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.
Failure to yield
28 04 000035 KDDRLOWF31 CF0612P1 28[4] 000035
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $2281.87 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Veh dmg paid to date is $1281.87 Amount: $ 1281.87 Item/Date: Deductible Amount: $ 1000.00
)DRLOWF3
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $2281.87 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $2281.87 due
Item/Date: Amount: $ 2281.87 due
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 2281.87 due
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) N/A NAME:
NAME:
ADDRESS: ADDRESS:
TELEPHONE: () TELEPHONE: | )
71 8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:.
NAME: This is a pd only claim being made NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: | )
DATE: TIME: •AM 0PM DATE: TIME: •AM 0 PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
or all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate plac f accident by "X" and by showing house numbers or distances to street corner 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 BELIEVE THEM TO BE TRUE I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. 28 05 000035 KDDRLOWF31 CF0612P1 28(4) 000035
SIÓNATURE OF CLAIMANT OR AGENT
6-11-2025
Jeanette Hild for Farmers Insurance Exchange a/s/o Omar Torres
TYPE OR PRINT NAME DATE
Insurance Carrier
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) )DRL0WF3 RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 Scan or visit verify. add123.com to verify
AutoDataDirect, Inc.
Verification Code: CECT2S2
California Vehicle Record
Retrieved On: Wed May 14, 2025 12:28:41 PM EDT
Reference ID: 7008971716-1
Registration Data Vehicle Data Tille Dara
Tag: 9RYJ770 VIN: Title:
Issue Date: 03/11/2025 Year: 11 Issue Date: 03/10/2025
Exp. Date: 05/02/2026 Make: GMC Use: Automobile - Used (12) ...
County: SAN BERNARDINO Model: Terrain* Odo Read: 15
(36) Trim: SLE* Odo Status: ACTUAL
Plate Type: Regular Auto (11) Body: Station Wagon (SW) Odo Date: 04/30/2011 03A1203 1710 A
Reg. Exp. Date: 05/02/2026 Class Code: AF
Fuel: Gas (G)
Curb Weight: 3,853*
Year First Sold: 11
Year Transferred: 25
Conditions
Date: 03/11/2025 Message: SMOG DUE 05/02/27
Message: NO MAILING ADDRESS
Date: 03/11/2025 Message: PREV LIC
DMV Fees for period 05/02/202s - 05/0122026 Date of Loss: 05/13/2028 _Description Amount Prorated Amount
ATD FEE: $2.00 $2.00
TRANSFER FEE: $15.00 $15.00
ALT FUEL TECH REG FEE: $3.00 $3.00
REG FEE: $71.00 $71.00
AQMD FEE: $7.00 $7.00
TRANSPORTATION IMPROVEMENT FEE: $32.00 $32.00
SAFE FEE: $1.00 $1.00
CHP FEE: $32.00 $32.00
TRANSFER SMOG FEE: $8.00 $8.00
VLF UNUSED PORTION: $5.50 $5.50
FINGERPRINT FEE: $2.00 $2.00
Settlement Total to Registered Owner: $25.00
Refund DMV Fees for period 05/02/2025 - 05/01/2026
Company Refund: $0.00
Vehicle Interests
Owner 1 TORRES OMAR
28 06 000035 KDDRLOWF31 CF0612P1 28[4] 000035
305 WHIPPLE MOUNTAIN RD
SN BERNRDNO, CA 92410
Raw Record Data
[ABANDONED_VEHICLE_FEE) hon commerciel vehicle in env county 153.003 [ABANDONED_VEHICLE_FEE| no county fee associated with acquiredDate with 05/02/2025 and county 36 [$2,093
ALT FUEL TECH REG FEE) Alternate Fuel Technology Regulation Fee: [$3.601 36 and zip 92410 and acquirediate after 4/30/2905 [$7.09] [ATO_FEET from county36 and is no: CVRA after 7/1/2016 [$2. 90]
[CARGO_THEFT_FEE) unladen weight is less than 10.002 2bs (S9.00] ICHP FEE) is not CVRA and accuired after 03/01/2021 | $32.001 ICHP. PENALTY_FEE: record 19
¡COUNTY TRANS PROJECT FEET No County Transport Profect Fee in county 36 during 05/02/2025 [$0.00) PANGERPRINTFEEE nONCRA vehicle from county 36, 05/02/2825 [$2.603 [MOTORCYCLE SAFETY FEE) vehicle is not a motorcycie 153,993 [PLATE_ INTERCHANGE SEQUENCE_FEE Vehicle does not have personalized plates [30.00] [PLATE,_INTERCHANGE_PERSONALIZED_FEE] vehicle does not have personalized plates [$0.00] [RES FEE] vehicle is registered after
[REG_FEE PENALTY] record is not expired [$0.00]
[REG_FEE_SURCHARGE] vehicle is registered in county 36 [$3.00] ROAD IMPROVEMENT FEET not a Zero emissien vehicle with a vehicle year on or after 2020 [$3.00] [SAFE_FEE 1 OVRA vanicle from county 36 or 03/10/2925 is elicible for fee r$1.03 [SALES_TAX} From 92430in county 36
salvaged [$0.00]
[TRANSFER_FEE] 5:73
under and uses gasoline [$6.00]
[TRANSPORTATION IMPROVEMENT_FEE] venicle has class code AF [$32.30] -. 0 FUSEL TAX] vehicle doesn't have use 2025 JUN 1S FM: 01 CITY OF RIALTO (VLF_PENALTY] fees are not expired (80.00]
[LER VeNICe 15 as commercial 120.001 vehicle is not
[WEIGHT_FEE PENALTY] expiration date after date record pulled [$3.00] (OPPA 6) Insurance underwriting, rating, claims and antifraud.
This information is provided by the Calfornia Department of Motor Vehicies (CaMV). Auto Data Direci, Inc. is'an authorized provider of real-time California motor vehicle data. Auto Data Direct, Inc. is not responsible for the unauthorized use of the information provided from the CaDMV.
This Motor Vehicle Record is extracted directly from the State or Jurisdiction's official Motor Vehicle Records database, in real time. The authenticity of these records may be authenticated in real time using the ADD on-ine authorization system.
Personal information (including, but not limited to: name, address, date of birth, Du number) appearing on driver and vehicle records is protected by the Driver Privacy Protection Act (DPPA). The use of personal information for reasons not allowed by the DPPA will result in loss of information access privileges and may result in legal action.
This record must not be reproduced, reused or resolt.
Any person who knowingly discloses any information in violation of the Driver Privacy Protection Act (DPPA) may be subject to criminal sanctions and civil liability specified in law for unauthorized use of the data.
* Fieid information provided by Auto Data Direct, inc.
50 40
20 10
MPH
Odometer
Claim Reference Id 7008971716-1_A6058992
File Name Odometer CITY CLEAR JUN 13 PM 1: 01 CITY OF RIALTO File Date 05/22/2025
Label Odometer
VIN
Note
Photo Location 34.0713913 (Lat), -
117.401038 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
8309.
22026
103 18 0428130 SooN
- 1:7
Vehicle Registration
Claim Reference Id 7008971716-1_A6058992
File Name Vehicle Registration LLEA LIVE: JUN 18 PM 1: 01 CITY OF RIALTO File Date 05/22/2025
Label Vehicle Registration
VIN
Note
Photo Location 34.0713913 (Lat), -
117.401038 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
Driver Side Front
Claim Reference Id 7008971716-1_ A6058992
File Name Driver Side Front CITY CILA* RECEIVED
2025 J0.18 PM 4: 01 CITY OF RIALTO
File Date 05/22/2025
Label Driver Side Front
VIN
Note
Photo Location 34.0713385 (Lat), -
117.400911 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
Say 22, 3023 15429
Driver Side Rear
Claim Reference Id 7008971716-1_A6058992
File Name Driver Side Rear
File Date 05/22/2025 CITY CLERK RECEIYED 2025 JUN 1S PM 4: 01 CITY OF RIALTO Label Driver Side Rear
VIN
Note
Photo Location 34.0713385 (Lat), -
117.400911 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
as Crest: Tame
Passenger Side Rear
Claim Reference Id 7008971716-1_A6058992 2025 JON 13
File Name Passenger Side Rear
File Date 05/22/2025 CITY CLLEX RECLIVED CITY OF RIALTO Label Passenger Side Rear
VIN
Note
Photo Location 34.0713385 (Lat), -
117.400911 (Lon)
: X-CLUSIVE KUSTOMZ ::
Photo Taken By
Lo 2:L/319 L
Passenger Side Front
Claim Reference Id 7008971716-1 A6058992
File Name Passenger Side Front
File Date 05/22/2025
Label Passenger Side Front CITY CLERA RECLIVID
VIN CITY OF RIALTO
Note
Photo Location 34.0713385 (Lat), -
117.400911 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
38L0g-114085
Damage - Left Angle CITY JUN 18
Claim Reference Id 7008971716-1 A6058992
File Name Damage - Left Angle IVE CITY OF RIALTO
File Date 05/22/2025
Label Damage - Left Angle
VIN PH: 4: 01
Note
Photo Location 34.0713181 (Lat), -
117.4009883 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
Damage - Center
Claim Reference Id 7008971716-1 A6058992
File Name Damage - Center
File Date 05/22/2025 Y CLERA GEIVED. 205 JUN 13 PH 01 CITY OF RIALTO Label Damage - Center
VIN
Note
Photo Location 34.0713181 (Lat), -
117.4009883 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
MFD BY GENERAL MOTORS OF CANADA LTD.
GM GUWA GAWA FAT GAWR RA
2250 KG 1175 KG 1240 KG
4961 28 2590 L8 2730 L8
THIS VEHICLE CONFORMS TO ALL APPLICABLE UIS. FEDERAL MOTOR
VEHICLE SAFETY AND THEFT PREVENTION STANDARDS IN EFFECT ON
THE DATE OF MANUFACTURE SHOWN ABOVE
TYPE: M.P.M.
MODEL: LF26
LEFC / TIRE SIZE SPEED ATO RIM COLD TIRE PRESSURE
P235/60R17 17X7J 2A0KPAOSPSD
AR P236/60A17 17X7J 240KPA/35PSO
SPA T146/70817 M 17X4 ST.
SEE OWNER'& MANUAL LILD FOR MORE INPORMATION.
May 22, 3023-35:02028 Pal Copigh Tame
VIN
Claim Reference Id 7008971716-1_A6058992
File Name VIN
File Date 05/22/2025
Label VIN
VIN
Note CHIT CLERA
2025 JUN 18 PM 4: 01 CITY OF RIALTO
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
08 LE
Damage - Right Angle
Claim Reference Id 7008971716-1_A6058992
File Name Damage - Right Angle
File Date 05/22/2025
Label Damage - Right Angle
VIN
RECEIVED 2025 JUN 13 PH 4: 01 CITY OF RIALTO
Note
Photo Location 34.0713181 (Lat), -
117.4009883 (Lon)
Photo Taken By : X-CLUSIVE KUSTOMZ
FARMERS INSURANCE EXCHANGE
CA - SOUTH COAST
*** SUPPLEMENT INSTRUCTIONS***
If the estimate warrants a supplement, please e-mail the appraiser listed below. Attach photos and/or documentation needed to support the request. As an alternative we can set up a video conference call at a cell number you provide. Claim Payments are made digitally - ask me how to register your business for this and all future claims.
2970 E. INLAND EMPIRE BLVD
SUITE 200
ONTARIO, CA 91764 Claim #: 7008971716-1_A6058992
Phone: (909) 472-0500 Workfile ID: 50955d0e
Supplement of Record 1 Summary
Written By: JESUS MARTINEZ, 5/27/2025 2:28:29 PM
Adjuster: THIS, SARAH, (916) 727-4621 Business
Insured: X-dusive Kustomz Owner Policy #: 0194850930 Claim #: 7008971716-1_A6058992 Type of Loss: COLL1 - MD Date of Loss: 05/13/2025 02:36 AM Days to Repair: g Point of Impact: 10 Left Front Pillar Deductible: 1000.00 (Left Side)
Owner (Insured): Inspection Location: Repair Facility:
X-clusive Kustomz Virtual
Cellular
2025
VEHICLE
mini
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black
CITY OF RIALTO
VIN: Production Date: 04/2011 Interior Color: "Jet Black y License: Odometer: 115610 Exterior Color:
State: CA Condition:
TRANSMISSION Air Conditioning Stereo Communications System Automatic Transmission Intermittent Wipers Search/Seek Hands Free Device POWER Tilt Wheel CD Player SEATS
Power Steering Cruise Control Auxiliary Audio Connection Cloth Seats Power Brakes Rear Defogger Satellite Radio Bucket Seats Power Windows Keyless Entry SAFETY WHEELS
Power Locks Message Center Drivers Side Air Bag Aluminum/ Alloy Wheels Power Mirrors Rear Window Wiper Passenger Air Bag PAINT Heated Mirrors Telescopic Wheel Anti-Lock Brakes (4) Clear Coat Paint DECOR Climate Control 4 Wheel Disc Brakes OTHER
Dual Mirrors Backup Camera Traction Control Fog Lamps
Privacy Glass RADIO Stability Control California Emissions Console/ Storage AM Radio Front Side Impact Air Bags
27/2025 2:28:29 PM 068414 | 1.9.07.03270 Page 1
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE•1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black CONVENI ENCE AM Radio Head/Curtain Air Bags
CITY CLENA RECEIN: CITY OF RIALTO
27/20252:28:29 M 068414 | 1.9.07.03270 Page 2
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black Line Oper Description Part Number Qty Extended Labor Paint Price $
# S01 Supplement Guidelines 1
NOTE: * Contact the appraiser via email for supplements. "There may be variance in labor rates between estimates * Price-match equal quality parts with any supplier.
* Get authorization for extra repair time with damage photos. * Send photos of damage on all supplemental parts.
2 FRONT BUMPER & GRILLE
3 O/H front bumper 2.8
4 **<> Repl A/M CAPA Bumper cover P95702 1 228.73 Ind. 3.0 5 Add for Clear Coat 1.2
Add for fog lamps 0.4
: Repl AM CAPA Lower cover REPG017504 197.92 Ind.
8 R&I RT Fog lamp bezel 25818476 Incl.
: Repl A/M CAPA LT Fog lamp bezel REPGO18902 1 48.59 Incl.
R&I Grille assy w/o chrome pkg 22764303 Incl
11 FRONT LAMPS
12 Repl LKQ LT Headlamp assy + 20% 00016709 1 96.00 0.5 13 Aim headlamps 0.5
14 Repl A/M CAPA LT Fog lamp assy S107902 1 40.71 Incl
Aim fog lamps 0.3
HOOD
= Rpr Hood 23393271 2.0 2,8
18 Overlap Major Non-Adj. Panel 2025 JUN 13 0.2
19 Add for Clear Coat 0.5
20 # Refn Base Coat reduction 8.3
21 # Refn .5 to spot underide repair of hood 70.5
under refinish CLERAO ISLi
22 R&I Insulator 84057182 PH L: 02 LTO
23 Ral Molding assy 19433469 0.3
FENDER
25 Repl LKQ LT fender assy + 20% 7167 1 180.00 1.4 22
26 Overlap Major Adj. Panel -0.4
27 Add for Clear Coat 0.4
28 : Repl AIM CAPA LT Fender liner REPG222110 1 38.27 Ind. 29 R&I LT Lower molding 22945685 0.2
30 R&l Mud guard 19170501 0.2
NOTE: Time is for Lt mud guard.
31 MISCELLANEOUS OPERATIONS
32 # Subl | Hazardous Waste 1 5.00 X
33 # Flex Additive 1 12.00 X
34 # Cover car for Overspray 1 5.00 0.2
35 # Corrosion Protection 5.00 T 0.2
SUBTOTALS 857.22 9.3 9.7
27/2025 2:28:29 PM 068414|1.9.07.03270 Page 3
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 835.22
Body Labor 9.3 hrs @ $ 51.75 /hr 481.28
Paint Labor 9.7 hrs @ $ 51.75/hr 501.98
Paint Supplies 9.7 hrs @ $ 36.00/hr 349.20
Miscellaneous 22.00
Subtotal 2,189.68
Sales Tax $1,189.42 @ 6.0000% 71.37
County Tax $1,189.42 1.2500% 14.87
Other Tax 1 $1,189.42 @ 0.5000% 5.95
Total Cost of Repairs 2,281.87
Deductible 1,000.00
Total Adjustments 1,000.00
Net Cost of Repairs 1,281.87
MyPriceLink Estimate ID:
1355208155566448640
CITY CLER* RECLIVE: 2025 JUN 18 PM 4: 02 CITY OF RIALTO 27/20252:28:29 PM 068414 | 1.9.07.03270 Page 4
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Addeditems
# S01 Supplement Guidelines
NOTE: * Contact the appraiser via email for supplements. * There may be variance in labor rates between estimates. * Price-match equal quality parts with any supplier.
Get authorization for extra repair time with damage photos. * Send photos of damage on all supplemental parts.
SUBTOTALS 0.00 0.0 0.0
TOTALS SUMMARY
Category Basis Rate Cost $
Parts 0.00
Subtotal 0.00
CUMULATIVE EFFECTS OF SUPPLEMENTS)
Estimate 2,281.87 ESTIMATOR 6
ESTIMATOR
Supplement S01 0.00 JESUS MARTINEZ
Workfile Total: $ 2,281.87 2075 JUN 18 PH 4:02 CITY OF RIALTO TOTAL ADJUSTMENTS: $ 1,000.00
NET COST OF REPAIRS: $ 1,281.87
My PriceLink Estimate ID:
1355208155566448640
27/20252:28:29 PM 068414 | 1.9.07.03270 Page 5
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE 1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black 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.
FOR YOUR PROTECTION CALI FORNIA 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 COLIVLU 2025 JUN 18 PM 4: 02 CITY OF RIALTO
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, INC= INCLUDED, MI SC= 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
27/20252:28:29 PM 068414 | 1.9.07.03270 Page 6
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black
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
WINDSHI ELD 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.
CITY CLEN* ALCLIYCL 2075 JUN 18 PM 4: 02 CITY OF RIALTO 27/20252:28:29 PM 068414 | 1.9.07.03270 Page 7
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx 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 DR1FJ10, CCC Data Date 05/15/2025, 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. 23.
SYMBOLS FOLLOWING LABOR:
D- Diagnostic labor category. E Electrical labor category. F= Frame labor category. G Glass labor category morie 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&l = 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.
COC 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:
28 25 000035 KDDRLOWF31CF0612P1 CF0612P1 28[4] 000035 BAR= Bureau of Automotive Repair. EPA= Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR= Paintless Dent Repair. VIN= Vehicle Identification Number. 27/20252:28:29 PM 068414 | 1.9.07.03270 Page 8
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx 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 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.
CITY CLERA ECEIVE. CITY OF RIALTO
27/20252:28:29 PM 068414 | 1.9.07.03270 Page 9
Claim #: 7008971716-1_A6058992
Workfile ID: 50955d0e
Supplement of Record 1 Summary
2011 GMC Terrain SLE-1 FWD 4D UTV 4-2.4L Gasoline SIDI Onyx Black
ALTERNATE PARTS SUPPLIERS
Line Supplier Description Price
4 Pacific Auto Company Ontario #P95702 $ 228.73
John Perez AIM CAPA Bumper cover
1131 PHILADELPHIA STREET
ONTARIO CA 91761
(800) 722-8890
7 Carparts Wholesale - Las Vegas #REPGO17504 $ 197.92
6271 E Azure Ave Delivery Door 22-23 A/M CAPA Lower cover Las Vegas NV 89115 Quote: 30552488
(888) 566-5883 Expires: 05/23/25
9 Carparts Wholesale - Las Vegas # REPG018902 $ 48.59
6271 E Azure Ave Delivery Door 22-23 A/M CAPA LT Fog lamp bezel Las Vegas NV 89115 Quate: 30552488
(888) 566-5883 Expires: 05/23/25
12 My Auto Store- Team PRP. #00016709 $80.00
201 N Front Si. LKQ LT Headlamp assy +20%
Camden NJ 08102 4WD 3.00L PROD DATE: 2011-01-01 999999MI - L (888) 900-1545 Quote: OOC-303019769
Expires: 06/01/25
14 Carparts Wholesale - Las Vegas #S107902 | $ 40.71
6271 E Azure Ave Delivery Door 22-23 AIM CAPA LT Fog lamp assy 223 Las Vegas NV 89115 Quote: 30552488
(888) 566-5883 Expires: 05/23/25
25 Walker 400 Auto Dismantling #7167 = $ 150.00
Sales Number LKQ LT fender assy + 20%
13107 Whittram Ave. FRONT FENDER LT-LH, BLACK, S# 7167 - L.
Rancho Cucamong CA 91739
(909) 463-6396
28 Carparts Wholesale - Las Vegas #REPG222110 $ 38.27
6271 E Azure Ave Delivery Door 22-23 A/M CAPA LT Fender liner 28(4) 000035 Las Vegas NV 89115 Quote: 30552488
(888) 566-5883 Expires: 05/23/25
KDDRLOWF31 CF0612P1
27 000035
27/2025 2:28:29 PM 068414 | 1.9.07.03270 Page 10
Toll Free: (800) 435-7764
mail: [email protected]
FARMERS Please include your claim # on any correspondenc INSURANCE National Document Center
June 12, 2025 Oklahoma City, OK 73126-8994
www.fatmets.com/claimstatus
Payment Log
Account Number: JJJ410301
Date of Loss: 05/13/2025
Insured's Name OMAR TORRES
Claim Number: 7008971716-1
Unit Type Claim Unit Date Issued Payee Check Number Payment 05/28/2025 OMAR TORRES 51.28137
Vehicle 1642677185
Payment Total: $1,281.87
Collections Total : $0.00
Deductible: $0.00
Grand Total : $1,281.87
CITY CLERY ECEIVLA 2025 JUN 18 PM 4: 02 CITY OF RIALTO
KDDRLOWF3 Page 27 of 27
28 01 000035 KDDRLOWF31 CF0612P1 28[4] 000035
FARMERS
INSURANCE June 12, 2025
National Document Center
P.O. Box 268994
Oklahoma City, OK 73126-8994
000035
SELF INSURED HUMAN RESOURCES CITY OF RIALTO 2025 JUN 17 PM 2:52 RECEIVED 150 S PALM AVE
RIALTO CA 92376
CITY CLERK RECEIVE. 2025 JUN 18 PM i: 01 CITY OF RIALTO Toll Free: (800) 435-7784
Emad myclain@ farmersinsurance com
FARMERS National Document Center
INSURANCE •P.O. Box 268992
Oklahoma City. OK. 73126-8992
Fax: (837) 217-1389
06/11/2025
City Of Rialto-City Clerk
150 S Palm Ave
Rialto, CA 92376
2325 JUN 13
Our Insured: Omar Torres
Our Claim #: 099 SUB 7008971716-1 CITY OF RIALTO
Date of Loss: 05/13/2025
Your Insured: Courtney Lyon
Your Claim #: PA 4: 01
Deductible Amount: $1,000.00
Total Amount Owed: $2,281.87
Dear City Of Rialto-City Clerk:
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 materia lamage, 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 $2,281.87.
Our theory of liability is as follows: On 5-13-2025 at appx 2:36pm on Baseline and Riverside, CA, Courtney Lynn driving City of Rialto PD veh at time of loss hit our insured driver Rianna Torres as insured was pulling back out into traffic from pulling over prior for a police officer going by with sirens on. Officer Lynn did not have sirens on when passing 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 980000 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.
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
IDRLOWF3
Thank you,
Jeanette Hild
Litigation Claims Representative
Farmers Insurance Exchange
616-803-7667 (Call/Text)
CITY CLERA RECENE 2025 JUN 13 PA 4: 01 CITY OF RIALTO
)DRLOWF3