CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2025 JUL 17 AMID: 30
RECLINE
1. Claims for death, injury to person, or to personal property must be filed not lafer than six (6) months after the occurronce (Gov. Code $9713).
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:
Arthur I. Patino
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TÉLEPHONE NO.
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: 06/28/2025 TIME: 10:30 * AM D 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. 10 Fwy E/B between Sierra and Cedar offramp - Rialto PD Patrol SUV driving over 100mph flew past me on the emergency lane as I was driving on the fast lane, no lights or sirens. The officer caused rocks, debris and dirt to fly into my driver door and rear. miles away officers had pulled over a U-haul truck.
3. HOW DID DAMAGE OR INJURY OCCUR?
Damage was caused from rocks and debris hitting the driver side of my car from carelessness of officer driving.
4. WERE POLICE AT THE SCENE? [YES DINO WERE PARAMEDICS AT THE SCENE? DYES KI 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.
Rialto Police Department SUV Patrol vehicle driven excessive speed for condition of the road.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ $4,742.67 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $. 4,742.67 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $.
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $. 4,742.67
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: N/A NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: )
DATE: TIME: CAMP DATE: TIME: L AM LI 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 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.
JUL
ITY OF RIALTO
CURB I:
PARKWAY
SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFYAOR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Arthur Khurin 07/16/2025
TYPE OR PRINT NAME DATE
Owner
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 ABS COLLISION CENTER INC Workfile ID: Tb660926
Federal ID: 46-3233122
"Where Quality is the Foundation to Our Success" State ID: EH-102437947 State EPA: CAL000388670
17250 Valley Blvd, [email protected], BAR: ARD00274385
HAIR FACILITY
FONTANA, CA 92335
Phone: (909) 829-1188
FAX: (909) 829-1088
Preliminary Estimate
Customer: Patino, Arthur
Written By: Octavious David
Insured: Patino, Arthur Policy #: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 09 Left T-Bone (Left Side)
Owner: Inspection Location: Insurance Company:
Patino, Arthur ABS COLLISION CENTER INC CUSTOMER PAY
17250 Valley Bivd
[email protected]
FONTANA, CA 92335
Repair Facility
(909) 829-1188 Business
VEHICLE
2017 DODG Charger R/T Scat Pack RWD 4D SED 8-6.4L Gasoline Sequential MPI GRAY VIN: Interior Color: Mileage In: Vehicle Out:
License: Exterior Color: GRAY Mileage Out:
State: CA Production Date: 4/2017 Condition: Job #:
TRANSMISSION Air Conditioning AM Radio Cloth Seats
Automatic Transmission Intermittent Wipers FM Radio Bucket Seats POWER Tilt Wheel Stereo Reclining/Lounge Seats
Power Steering Cruise Control Search/Seek WHEELS
Power Brakes Rear Defogger Auxiliary Audio Connection 20" Or Larger Wheels Power Windows Keyless Entry Satellite Radio PAINT
Power Locks Alarm SAFETY Clear Coat Paint
Power Mirrors Message Center Drivers Side Air Bag OTHER Power Driver Seat Steering Wheel Touch Controls Passenger Air Bag Fog Lamps Power Passenger Seat Telescopic Wheel Anti-Lock Brakes (4) Traction Control DECOR Climate Control 4 Wheel Disc Brakes Stability Control Dual Mirrors Remote Starter Front Side Impact Air Bags Rear Spoiler Tinted Glass Backup Camera Head/Curtain Air Bags California Emissions Console/Storage Parking Sensors Positraction
Overhead Console Home Link Hands Free Device
CONVENIENCE RADIO SEATS
Get live updates at www.carwise.com/e/58fHjZ
7/12/2025 11:16:33 AM 309269 Page 1
Preliminary Estimate
Customer: Patino, Arthur
2017 DODG Charger R/T Scat Pack RWD 4D SED 8-6.4L Gasoline Sequential MPI GRAY Line Oper Description Part Number Qty Extended Labor Paint Price $
1 # ESTIMATE(S) BASED ON A 1
VISUAL INSPECTION ONLY
# ADDITIONAL DAMAGES MAY BE 1
FOUND AFTER DISASSEMBLY
3 # REPAIRS OR REPLACEMENT OF 1
ADDITIONAL PARTS MAY BE
NEEDED
4 FRONT BUMPER & GRILLE
5 R&I R&I bumper cover 1.9
6 FRONT LAMPS
7 R&I LT R&I headlamp assy 0.3
8 FENDER
9 * BInd LT Fender 1.6
10 R&I : LT Fender liner 6.2, 6.4 liter 0.3
11 FRONT DOOR
12 * Rpr LT Outer panel (HSS) 2.0 2.1
13 Add for Clear Coat 0.8
14 R&I LT Belt w'strip 0.3
15 R&I LT Applique 0.2
16 R&I LT Power mirror w/o heat 0.5
17 * R&I LT Run channel 2.3
18 R&I LT Mount plate 0.6
19 R&I LT R&I trim panel 0.5
20 R&T LT Handle, outside destroyer gray 0.4
21 REAR DOOR
22 * Rpr LT Outer panel (HSS) 3.0 2.0
23 Overlap Major Adj. Panel -0.4
24 Add for Clear Coat 0.3
25 R&I LT Belt w'strip 0.3
26 R&I LT Rear w'strip 0.2
27 R&I LT Door w'strip 0.4
28 R&I LT Handle, outside destroyer gray 0.4
29 R&I LT Lower w'strip 0.2
30 R&I LT R&I trim panel 0.5
31 QUARTER PANEL
32 * Rpr LT Quarter panel 5.0 2.6
33 Overlap Major Adj. Panel -0.4
34 Add for Clear Coat 0.4
35 TRUNK LID
36 * Rpr Trunk lid w/o police w/camera 2.0 2.3
37 Overlap Major Adj. Panel -0.4
38 Add for Clear Coat 0.4
39 * R&I Nameplate "CHARGER" black 0.2
7/12/2025 11:16:33 AM 309269 Page 2
Preliminary Estimate
Customer: Patino, Arthur
2017 DODG Charger R/T Scat Pack RWD 4D SED 8-6.4L Gasoline Sequential MPI GRAY 40 Repl Nameplate "CHARGER" black 68216156AB 1 80.75 0.2 41 Repl Nameplate "Scat Pack" 68394696AA 147.00
42 # R&I Spoiler 1.5
43 REAR LAMPS
44 R&I LT Tail lamp assy 0.3
45 R&I RT Tail lamp assy 0.3
46 REAR BUMPER
47 O/H bumper assy 3.0
48 * Rpr Bumper cover w/rev sensr 4.0 3.2
49 Add for Clear Coat 1.3
50 VEHICLE DIAGNOSTICS
51 * Rpr Pre-repair scan m 0.5
52 MISCELLANEOUS OPERATIONS
53 # Refn Featheredge and Prime 1.0
54 * Rep! Cover car/bag 1 10.00 0.5
55 # Repl Color sand buff 1 3.0
56 ** ReplA/M Mask for primer 1 10.00 T 0.5
57 # Subl HAZARDOUS WASTE - CA 1 25.00 X
58 ** Repl A/M Etch Bare Metal 1 10.00 T 0.5
59 # Refn COLOR TINT 0.5
SUBTOTALS 282.75 33.8 17.3
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 237.75
Body Labor 33.8 hrs $65.00/hr 2,197.00
Paint Labor 17.3 hrs @ $65.00/hr 1,124.50
Paint Supplies 17.3 hrs @ $60.00/hr 1,038.00
Miscellaneous 45.00
Subtotal 4,642.25
Sales Tax $1,295.75 @ 7.7500 % 100.42
Grand Total 4,742.67
7/12/2025 11:16:33 AM 309269 Page 3
Preliminary Estimate
Customer: Patino, Arthur
2017 DODG Charger R/T Scat Pack RWD 4D SED 8-6.4L Gasoline Sequential MPI GRAY
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
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT.
''''CURE TIME'' MEANS THE LENGTH OF TIME THAT, PER THE ADHESIVE
MANUFACTURER, THE WINDSHIELD ADHESIVE NEEDS TO CURE UNTIL THE
WINDSHIELD CAN PROPERLY FUNCTION AS A SAFETY DEVICE PURSUANT
TO THE FEDERAL MOTOR VEHICLE SAFETY STANDARDS AND THE
VEHICLE MANUFACTURER'S SPECIFICATIONS.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS
ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE.
7/12/2025 11:16:33 AM 309269 Page 4
Preliminary Estimate
Customer: Patino, Arthur
2017 DODG Charger R/T Scat Pack RWD 4D SED 8-6.4L Gasoline Sequential MPI GRAY 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 DR3PB11, CCC Data Date 07/10/2025, and potentially other third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are manufactured by or for the vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts are available at OE/Vehicle dealerships or the specified supplier. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships with discounted pricing. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor data provided by third party sources of data may have been modified or may have come from an alternate data source.
Tilde sign (~) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non OEM, A/M or NAGS. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2024 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. CFC=Carbon Fiber.
D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel. Incl.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF International Certified Part.
O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. Sect=Section. STS=Stainless Steel. Subl=Sublet.
UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Intelligent Solutions Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 7/12/2025 11:16:33 AM 309269 Page 5