CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CITY 2075 AUG 20 P: 5:34
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY MECEIVED
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:
United Financial Casualty Company A/S/O LUCES, FRANKLIN
FULL NAME DATE OF BIRTH
PO BOX 94639 CLEVELAND, OH 44101 1877) 818-0139
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE 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: 12/31/2024 TIME: 08:00 PM PT • AMO 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. 1312 EAST ONTARIO AVENUE, 92881 CORONA, CA USA
3. HOW DID DAMAGE OR INJURY OCCUR?
PROGRESSIVE WAS 1312 EAST ONTARIO AVENUE, 92881
YOUR VEHICLE DRIVEN ROBERT JOHN BAXSTER BACKED INTO PROGRESSIVE VEHICLE.
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.
YOUR VEHICLE DRIVEN BY ROBERT JOHN BAXSTER BACKED INTO PROGRESSIVE VEHICLE
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 4,098.11 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 2017 TOYOTA COROLLA- PS QUARTER PANEL Amount: $_4,098.11 Item/Date: Amount: $.
4,098.11
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
Or RIALIG
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 2225 ANG 20 Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 4,098.11
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: DAM • PM DATE: TIME: •AM •PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names af streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street corners.
When you i sacry on eide at or grown ete the fate year and at yal our eid a retror eric. 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
71 SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Megan McCallough 8/11/25
TYPE OR PRINT NAME DATE
United Financial Casualty Company- SUBROGATION SPECIALIST
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376
CITY OF FIALTO PROGRESSIVE
Payment Address Document Address
1025 ANG 20 PETS: S:34 24344 Network Place P.O. Box 94639 Chicago, IL 60673-1243 Cleveland, Ohio 44101-990
42061% Phone: (877)818-0135
Fax: (888) 781-6947
8/8/2025 1:23:00 PM VITY GLEN
Certified Mail certified number 9489 0090 0027 6567 1752 25 Return Receipt Requested
CITY OF RIALTO
CITY CLERKS OFFICE
150 S PALM AVE
RIALTO, CA. 92376
Your Client: ROBERT JOHN BAXTER
Your Claim Number: NA
Our Insured: LUCES, FRANKLIN
Our Claim Number: 25-679110786
Amount Subject to Reimbursement: $4,098.11
Amount of Insured's Deductible: $1,000.00
Please take this as formal notice of our subrogation rights relative to the above -captioned claim. We have completed our investigation into the facts of the above-captioned loss and find that your insured was the proximate cause of the accident.
Location of Loss: 1312 EAST ONTARIO AVENUE, 92881 CORONA, CA USA Date and Time of Loss: 12/31/2024, 08:00 PM PT
Description of Loss: PROGRESSIVE WAS 1312 EAST ONTARIO AVENUE, 92881
YOUR VEHICLE DRIVEN ROBERT JOHN BAXSTER BACKED INTO PROGRESSIVE VEHICL Please make your draft payable to United Financial Casualty Company as subrogee of "LUCES, FRANKLIN" ", in the amount stated above and mail it to the attention of the undersigned at your earliest convenience.
All supporting documentation is enclosed. Thank you for your anticipated, prompt attention to this matter.
Progregsive Subrogation
United Financial Casualty Company
Tel. 877-818-0139
Fax. 888-781-6947
[email protected]
W-9 Request for Taxpayer CITY OF RIAL Give form to the
Form
(Rev. March 2024) Identification Number and Certification 23 requester. Do not 5: usend to the IRS
Department of the Treasury
Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information.
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below. 1 Name of entity/Individual. An entry is required. (For a sale proprietor or disregarded entity, enter the owner's name online 1, and enter the business/disregarded entity's name on line 2.)
United Financial Casualty Company
2 Business name/disregarded entity name, if different from above.
Зa Chack the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check 4 Exemptions (codes apply only to only one of the following seven boxes. certain entities, not individuals; • S corporation see instructions on page 3):
Individual/sole proprietor • C corporation Partnership Trust/estate LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) Exempt payee code (it any) Note: Check the "LLC" box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate Exemption from Foreign Account Tax Print or type. See Specific Instructions on page 3. box for the tax classification of its owner. Compliance Act (FATCA) reporting code (if any)
Other (see instructions)
3b It on line 3a you checked "Partnership" or "Trust/estate," or checked "LL" and entered "P" as its tax classification. (Applies to accounts maintained and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check outside the United States.) this box if you have any foreign partners, owners, or beneficiaries. See instructions. • 5 Address (number, street, and apt, or suite no.). See instructions. Requester's name and address (optional) 300 North Commons Blvd
6 City, state, and ZIP code
Mayfield Village, OH 44143
7 List account number(s) here (optional)
Part l Taxpayer Identification Number (TIN)
Social security number
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. Forother entities, it is your employer identification number (EIN). If you do not have a number, see How to get a or TIN, later. Employer identification number
Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter. 3 6 3 2 9 8 0 8 Part / Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and . I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the internal Revenue Service (IAS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that l an no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (deflned below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATA reporting is correct.
Certilication instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are ngt required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. 118/25
General Instructions New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect Section references are to the Internal Revenue Code unless otherwise foreign parlners, owners, or beneficiaries when it provides the Fom W-9 noted. to another flow-through entity in which it has an ownership interest. This Future developments. For the latest information about developments change is intended to provide a flow-through entity with information related to Form W-9 and its instructions, such as legislation enacted regarding the status of its indirect foreign partners, owners, or after they were published, go to www.irs.gov/FarmWWg. beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign What's New partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (For 1065).
Line 3a has been modified to clarily how a disregarded entity completes this line. An LLC that is a disregarded entity should check the Purpose of Form appropriate bax for the tax classification of its owner. Otherwise, it An individual or entity (Form W-9 requester) who is required to file an should check the "LL" box and enter its appropriate tax classification. information relum with the IRS is giving you this form because they Cat No. 10231X Fom W-9 (Rev. 3-2024)
8/8/25, 1:19 PM Claim Payment Detail
Claim Payment Detail (25-679110786 )
CITY OF RIALTO
- Payment Information
Disbursement Number: 231011754 Total Amount: U$3,098.11 5: 34 Draft Number: 6017664450 Invoice Number: 143384680
Pay to the Order of: FRANKLIN LUCES
Mailing Address:
In Payment Of: Progressive Invoice Number: 143384680
- Reviewed Summary
Issuing Rep: A214800 Approved By:
Issue Date: 05-14-25 Review Date:
Last Updated Rep: A214800 Reviewed By:
-Bank Information
Type: Loss Bank Code: 1CD
Stop Reason: Cleared: 05-23-25
Stop Date:
-Exposure Detail: COLL
Party Name: LUCES, FRANKLIN Amount Paid: $3,098.11
Property Description: 17 TOYOTA COROLLA Deductible Taken: $1,000.00 Payment Type: SUPPLEMENTAL PAYMENT
Renperty Damage: S000 $0.00
https://cla-claimsum-web-prod.prod.glb.pgrcloud.app/2025679110786/claim-payment-inquiry 1/1
CITY OF RIALTO
United Financial Cas Co Estimate ID
2075 AUG 20 : 3125-679110786-0
Original
RECEI Claim Number
25-679110786-01
Owner Insured Appraiser
FRANKLIN LUCES FRANKLIN LUCES RONALD SMITH
(951) 489-8211 (Work)
[email protected]
Underwriter
United Financial Cas Co
United Financial Cas Co
Claim Number Adjuster Deductible Reported Date
25-679110786-01 VANESSA SURPRISE 1000.00 - Not Waived 02/04/2025 (925) 278-5772 (Work)
[email protected]
Loss Date Inspection Site
12/31/2024 Not Available
1135 Greenhill Way
Corona, CA 92882
2017 Toyota Corolla LE 4 Door Sedan 1.8L 4 Cyl Gas Injected Auto Trans FWD Exterior Color License VIN Drivable
209 (Black Sand Pearl) Yes
Odometer Mitchell Service Code
125038 911632
Primary Point of Impact
Right Rear Side (4)
Options
Air Conditioning AM-FM Stereo Anti-Lock Brake Sys. (ABS) Auto Air Condition Automatic Headlights Automatic Transmission Auxiliary Input Bluetooth Wireless CD Player Cloth Seat Connectivity
Cruise Control Daytime Running Lights Driver-Front Air Bag Electric Defogger Electronic Stability Control First Row Bucket Seat Heated Mirror Keyless Entry System Left-Curtain Air Bag MP3 Player Passenger-Front Air Bag Power Door Locks Power Remote Mirror Power Steering Power Windows Rear Bench Seat Rearview Camera kelease Deckild Or Tailsate Second Row Side Airbag With Side Airbags Head Protection
Steering Wheel Mounted Tilt Steering Wheel Vest pressure Monitorine Traction Control/Electronic Trip Computer Audio Control
FRANKLIN LUcES | 2017 Toyota Corolla LE
Parts Profile Parts Profile Version
NORTH ALL PART TYPES 3.0
Committed On Version Mitchell Cloud Estimating™ Printed On Profile (Modified) Page 1 of5 4/8/2025 Mitchell Estimating 24.5 Copyright 1994-2025 Mitchell International, Inc. 4/8/2025 CA NORTH ALL PARTS 10:31 AM DEM MAR_25_V 10:31 AM Profile Version
All Rights Reserved 13.0
LABOR CITY OF RIALTO - PART
Line # Description Operation Type Total Units Type 20 P. Number Qty Total Price Tax Rocker / Pillars / Floor
1 101161 R Roof Rail Refinish Refinish 1.6#C Existing
Only CITY CLEAN
Rear Door
100897 RRear Door Repair Panel Remove / Body 7.5# New 67113-02190 1 $363.76 Yes (HSS) Replace
3 AUTO R Rear Door Outside Refinish Refinish 2.2C
Only
4 AUTO R Rear Add For Jambs Refinish Refinish 0.5 C
Only
5 100193 R Rear Otr Door Belt Remove / Body INC Existing Moulding Install
6 100901 RRear Door Blackout Tape Remove / Body 0.3# Aftermarket TO-8084 1 $22.05 Yes Replace New
7 900501 Per Toyota Non-Reusable
100180 R Rear Door Frt Window Remove / Body 0.2 New 75761-02030 1 $41.90 Yes Frame Midg Replace
900501 Per Toyota Non-Reusable
Part
10 101232 R Rear Door Trim Panel Remove / Body INC Existing Install
11 101230 R Rear Otr Door Handle Remove/ Body INC# Existing Install
12 100290 R Rear Door Weatherstrip Remove/ Body INCr Existing Install
13 100418 R Rear Door Moveable Remove / Glass INCr Existing Glass Install
Roof
14101170 RRoof Moulding Remove/ Body 0.3 Existing
Install
Quarter Panel
15 101552 R Quarter Outer Panel Assy Repair Body 16.0*# Existing 16 AUTO R Quarter Panel Outside Refinish Refinish 1.8C
Only
Rear Bumper
17 101248 Rear Bumper Cover Remove / Body 0.8 Existing
Install
18 101307 Rear Bumper Cover Repair Body 1.0° Existing
19 AUTO Rear Bumper Cover Refinish Refinish 3.0# C Existing Only
Additional Costs & Materials
20 AUTO Paint/Materials Additional $632.50 Yes
Cost
21 AUTO Hazardous Waste Disposal Actional $4.00*
Additional Operations
22 AUTO Clear Coat Additional Refinish 2.4 $0.00
Operation
Special/ Manual Entry
23 900500 SUSPENSION AND WHEEL Align Mechanical* 0.0* Sublet Sublet 1 $75.00'
ALIGNMENT
24 900500 Lionheart tire Remove / Body" 0.0* New 1 $77.00* Yes Replace
Committed On Version Mitchell Cloud Estimating™ Printed On Profic Mastied Page 2 of5 4/8/2025 Mitchell Estimating 24. Copyright 1994-2025 Mitchell International, Inc. 4/8/2025 CA NORTH ALL PARTS 10:31 AM 10:31 AM Profile Version
All Rights Reserved 13.0
CITY OF RIALTO
LABOR PART
Line # Description Operation Type Total Units?: Atype? P Number Qty Total Price Tax 5 900501 https://www.discounttirezo
.com/lionhart-Ih-503 MELLIS
22540zr18-92w-xl-p- CITY CLEMA
16015.html
gad_source = 1&gclid=EAlal
QobChMItMysqPf|jAMVjTE
IBRNAhBEAQYAABEgJz
yVD_BwE
* Judgment Item C Included in Clear Coat Calculation
T Included in Two Tone Calculation A Included in Clear Coat and Two Tone Calculation # Labor Note Applies r CEG R&R Time Used for this Labor Operation d Discontinued by Manufacturer [l Verify the part number and price beforeordering Parts Vendors
Alternative Emblems
1812 Mt. Carmel Church Rd
Chapel Hill NC 27517
(866) 462-3484 (Work)
Total
Line Part # Price
6 TO-8084 $22.05
Supplier Notes: Part sourced from SurePart
(powered by PartsTrader).
Disclaimer: This estimate has been prepared based on the use of crash parts supplied by a source other than the manufacturer of your motor vehicle. Any warranties applicable to these replacement parts are provided by the manufacturer or distributor of the parts, rather than by the original manufacturer of your vehicle.
Estimate Totals
Labor Units Rate Sublet Add'l Amount Totals
Body Labor 26.1 $74.00 $1,931.40
Refinish Labor 11.5 $74.00 $851.00
Glass Labor 0.0 $74.00 $0.00
Mechanical Labor 0.0$153.00 $75.00 $75.00
Total Labor 37.6 $75.00 $2,857.40
Taxable $0.00
Tax 0.0000% $0.00
Non-Taxable $2,857.40
Pre-Tax Discount 0.00% $0.00
Labor Total $2,857.40
Parts Amount
Taxable Parts $504.71 $504.71
Parts Adjustments $0.00
Tax 8.7500% $44.16
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Parts Total $548.87
Casts Amount
Committed On Version Mitchell Cloud Estimating™ Printed Or Profile Mosfied Page 3 of5 4/8/2025 Mitchell Estimating 245 Copyright 1994-2025 Mitchell International, Inc 4/8/2025 CA NORTH ALL PARTS 10:31 AM OEM MAR 25_V All Rights Reserved 10:31 AM Profile Version
13.0 CITY OF RIALTO
Estimate Totals
Paint Materials $632.50 2025 AUG 20 F 5: 34 $632.50
Shop Materials $0.00 $0.00
Other Additional $4.00 $4.00
Costs CITY CLERE
Paint Materials: Taxable $632.50
- Refinish Units: 11.5 units Tax 8.7500% $55.34
- Rate: $55.00 Non-Taxable $4.00
- Rate Max: 99.9 units Pre-Tax Discount 0.00% $0.00
- Additional Rate: $0.00 Costs Total $691.84
Gross Totals Amount
Gross Total $4,098.11 $4,098.11
Taxable $1,137.21
Tax $99.50
Non-Taxable $2,861.40
Pre-Tax Discount 0.00% $0.00
Gross Total $4,098.11
Adjustments Amount
Deductible -$1,000.00 -$1,000.00
Total Customer -$1,000.00
Responsibility
Net Estimate Total $3,098.11
Shop agrees to perform the specified repairs at the price indicated.
Repair Facility Authorized Signature
All manufacturers requirements regarding seat belt and supplemental restraint system replacement must be adhered to.
If additional parts or operations are necessary to properly accomplish this, please contact the estimating claims rep.
THIS APPRAISAL HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCEOTHER THAN THEMANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE
REPLACEMENT PARTS ARE PROVIDED BYTHE MANUFACTURER OR DISTRIBUTOR OFTHEPARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. WE WARRANT THE PARTS ARE AT LEAST EQUAL TOTHE ORIGINAL MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT, AND PERFORMANCE. *************IMPORTANT INFORMATION: READ CAREFULLY************* The customer has the right to select the repair shop. Pursuant to CA Code of Regulations sec 2695.8(e) Progressive does begin. This appraisal is not an authorization for repairs. If frame or unibody repair is included on this appraisal, the amount shown includes time or allowance for measuring before, during and after those repairs.
To ensure proper and prompt payment for additional damage discovered during the course of repairs, contact Progressive for supplement procedures. Progressive payments will not exceed the prevailing labor market rate in the area wherethe Committed On Version Mitchell Cloud Estimating™M Printed On Profile (Modified Page 4 of 5 4/8/2025 Mitchell Estimating 24.5 4/8/2025 CA NORTH ALL PARTS Copyright 1994-2025 Mitchell International, Inc.
10:31 AM Profile Veram
10:31 AM All Rights Reserved
13.0 CITY OF PIAI
property is to be repaired. Contact us if you choose a shop with rates higher than those reflected on this appraisal to determine whether an adjustment is appropriate. If you choose a shop that charges in excess of prevailing labor market rates, you will be responsible for the difference.
Lifetime guarantee for sheet metal and plastic parts. The replacement parts written on this appraisal are intended to return your vehicle to its pre-loss condition with proper installation. After repair, if any sheet metal or plastic body part included in this appraisal fails to return your vehicle to its pre-loss condition (assuming proper installation), in terms of form, fit, finish, durability or functionality, Progressive will arrange and pay for the replacement of the part, to the extent not covered by a manufacturer's or other warranty. This service will be performed at no cost to you (including associated repair and rental car costs). To obtain service under this Guarantee, call Progressive at 1-800-274-4641. This Guarantee applies as long as you own or lease the vehicle. This Guarantee is not transferable and terminates if you sell or otherwise transfer your vehicle.
THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS GUARANTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION.
ACCORDINGLY, PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF THESE PARTS.
California Residents: As required by California regulations, the legend below should be used to identify whether replacement parts listed on this appraisal are "new", "used", "rebuilt", or "reconditioned" and whether the crash parts described on this appraisal are "original equipment manufacturer" (OEM) parts or "non-original equipment manufacturer aftermarket crash" parts:
New, OEM or part number displayed = New, original equipment manufacturer part Aftermarket New, nonOEM aftermarket = New, non-original equipment manufacturer aftermarket crash part Remanufactured = Rebuilt used OEM part
Used, Quality Recycled Part = Used OEM part
Re-cored = Reconditioned used OEM part
Re-chromed = Reconditioned used OEM part
Sublet = Repair work assigned to third party
Existing = Part is already on the vehicle
Progressive's Lifetime Guarantee does not cover repairs you request the shop to make that are not related to this accident, including but not exclusive to unrelated prior damage and pre-existing damage.
Disclaimer: For your protection California law requires the following statement to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Cycle Time Information Estimate Event Log
Due In 4/8/2025 Job Created 4/7/2025 03:48 PM
Estimate Started 4/8/2025 08:47 AM
Estimate Printed 4/8/2025 10:31 AM
Estimate Committed 4/8/2025 10:31 AM
Estimate Version
Estimate Retrieval ID 10005379191
Committed On Version Mitchell Cloud Estimating ™M Printed On Profile (Modifical Page 5 of5 4/8/2025 Mitchell Estimating 24.5 Copyright 1994-2025 Mitchell International, Inc. 4/8/2025 CA NORTH ALL PARTS 10:31 AM OEM MAR 25 V All Rights Reserved 10:31 AM 118fie Version 8/8/25, 1:23 PM Claim: 25-679110786 01
Claim: 25-679110786 01 FRANKLIN LUCES
2596ca69-07fd-4324-ade5-51e72b9250b2.jpg 114d6e2f-f324-4c88-abac-e4d7613c18c9.jpg f265c641-41fc-430-8635-ccc065679f7 jpg 1f59577-4989-406c-b9dc-213h2d87720 jpg https://progressive.mymitchell.com/Claim/ClaimFileViewer/PhotoThumbnailView.aspx?CID=1081276343&SID=1118641696&FID=1351499174&CNUM.. 1/5 8/8/25, 1:23 PM Claim: 25-679110786 01
Claim: 25-679110786 01 FRANKLIN LUCES
b611e5b7-7c59-43d7-8b12-4ddc6edd6c2e.jpg 06fcfda4-26b6-45b6-a690-f3fbc70ede64.jpg Oc7e0ea4-7e0d-4236-8ff8-ac6de65c7dbc.jpg 892acec1-a1a0-44e2-8d26-4db3e26a8d0e.jpg https://progressive.mymitchell.com/Claim/ClaimFileViewer/PhotoThumbnailView.aspx?CID=1081276343&SID=1118641696&FID=1351499174&CNUM.. 2/5 8/8/25, 1:23 PM Claim: 25-679110786 01
Claim: 25-679110786 01 FRANKLIN LUCES
20 6be7e275-fa21-4b9a-a16f-8b9030d0d947.jpg 7d56879e-1393-4dfd-876d-a91f91445c5c.jpg 5f8d191e-1314-4834-b42e-868f3e3d3927.jpg fd41f96a-db25-4877-a264-b52eb3058cd7.jpg https://progressive.mymitchell.com/Claim/ClaimFileViewer/PhotoThumbnailView.aspx?CID=1081276343&SID=1118641696&FID=1351499174&CNUM... 3/5 8/8/25, 1:23 PM Claim: 25-679110786 01
Claim: 25-679110786 01 FRANKLIN LUCES
0f6d0f1b-864a-430e-9d1e-b568e2bec454.jpg 33720b90-5971-4ffc-89ee-485ae47f19c7.jpg 2bc2f6b3-f30f-48c2-bd45-97e2ec741cc4.jpg b86d65cc-9d86-413b-8d5c-75e67d6b5605.jpg https://progressive.mymitchell.com/Claim/ClaimFileViewer/PhotoThumbnailView.aspx?CID=1081276343&SID=1118641696&FID=1351499174&CNUM.. 4/5 8/8/25, 1:23 PM Claim: 25-679110786 01
Claim: 25-679110786 01 FRANKLIN LUCES
RIALTO
a91b1858-1ea3-4c1b-95c1-cf961300813a.jpg 65df78f1-04ad-4bcf-89d3-af2e6bddb6b8.jpg https://progressive.mymitchell.com/Claim/ClaimFileViewer/PhotoThumbnailView.aspx?CID=1081276343&SID=1118641696&FID=1351499174&CNUM.. 5/5 CITY OF RIALTO -or Customer Support refer to the
FI 5: 35 appropriate platform below:
LexisNexis?
Police Records Retrieval
RISK SOLUTIONS 800-934-9698
ITY CLER
[email protected]
For tips on ordering visit:
statetips.lexisnexisrisk.com Accurint for Insurance
866-277-8407
[email protected]
PAGE COUNT: 5
CLIENT: 107040
DIVISION: CALIFORNIAP198C
ADJUSTER: A214800
CLAIM: 25-934628688
TRANSACTION #: 3121805451
DATE: 2025-01-30 03:06:25.0
DATE OF LOSS: 01/31/2024 TIME OF LOSS: 20:00
STREET: 1312 EAST ONTARIO AVENUE
CITY: CORONA
COUNTY: RIVERSIDE
STATE: CA
INVESTIGATING AGENCY: CORONA PD
REPORT NUMBER: 24101416
REPORT TYPE: AUTOACCIDENT
PARTY1: FRANKLIN LUCES
PARTY2: ROBERT J BACKSTER
PARTY3:
CAR: MAKE: YEAR:
TAG:
ADDITIONAL INFO:
NOTE:
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STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
NUMBER HIT & RUN CITY CITYOFRIA JUDICIAL DISTRICT LOCAL REPORT NUMBER
SPECIAL CONDITIONS INJURED FELONY
CORONA r:35 CMC 24-101416
PRIVATE PROPERTY NUMBER HIT & RUN COUNTY 7975 AUG 20 REPORTING DISTRICT BEAT [DAY OF WEEK TOW AWAY KILLED MISD.
RIVERSIDE 13D Tuesday
COLLISION OCCURRED ON EMO.. DAY YEAR TIME (2400) INCIC # OFFICER ID. 1312 E ONTARIO AVE CLER 12/31/2024 2000 3315 |004274
MILEPOST INFORMATION GPS COORDINATES PHOTOGRAPHS BY • MONE 4F FEET LATITUDE LONGITUDE
OF
L AT INTERSECTION WITH STATE HWY REL VAN HORNE
N X OR FEET
PARTY DRIVER'S LICENSE NUMBER STATE MAKE / MODEL / COLOR [LICENSE NUMBER STATE 1 CA FORD TAURUS WHITE CA
DRIVER NAME (FIRST, MIDDLE, LAST) On Duty Emergency Vehicle ROBERT JOHN BAXTER OWNER'S NAME • SAME AS DRIVER
PEDES- STREET ADDRESS CITY OF RILATO
TRIAN
OWNER'S ADDRESS * SAME AS DRIVER
PARKED CITY / STATE / ZIP RIALTO, CA 92376
RIALTO 92376 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER XI DRIVER • OTHER
HAIR EYES HEIGHT WEIGHT BIRTH DATE RACE DRIVEN AWAY
BRO BRO 602 240 01/16/1969 PRIOR MECHANICAL DEFECTS: IX NONE APPARENT • REFER TO NARRATIVE HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
(909) 820-7575 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGE AREA INSURANCE CARRIER POLICY NUMBER 48 • UNK. O NONE 8 MINOR CITY OF RIALTO SELF INSURED • MOD. • MAJOR • KOLL-OVER
DIR OF TON STREET OR HIGHWAY (SPEED LIMIT DOT
TRAVEL Cм.т oil:
NORTH 1312 E ONTARIO AVE 15 TCP/PSC MC/X
PARTY TORIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE 2 CA M G 2017 TOYOTA COROLLA BLACK 9CQF087 CA
DRIVER NAME (FIRST, MIDDLE, LAST)
2 FRANKLIN JUNIOR LUCESROJAS OWNER'S NAME X SAME AS DRIVER
PEDES- STREET ADDRESS FRANKLIN JUNIOR LUCESROJAS
TRIAN
OWNER'S ADDRE * SAMEAS DRIVER
CORONA, CA 92882
CORONA CA 92882 DISPOSITION OF VEHICLE ON ORDERS OF: [OFFICER X DRIVER • OTHER
BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTH DATE RACE
CLIST DRIVEN AWAY
M BLK BRO 601 210 09/13/1988 H PRIOR MECHANICAL DEFECTS: * NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGE AREA INSURANCE CARRIER POLICY NUMBER • UNK. • NONE 8 MINOR
01 PROGRESSIVER 975192644 • MOD. • MAJOR • ROLL-OVER • 0
DIR OF TON SIREE OR HIGHWAY (SPEED LIMIT DOT
TRAVEL
EAST 1312 E ONTARIO AVE 15 CAL-T TCP/PSC MC/MX
PARTY TORIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE / MODEL / COLOR LICENSE NUMBER STATE 3 DRIVER NAME (FIRST, MIDDLE, LAST)
OWNER'S NAME • SAMEAS DRIVER
PEDES- STREET ADDRESS
TRIAN
UWNERS AUUKE • SAMEAS DRIVER
PARKE C CITY / STATE / ZIP
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER •DRIVER • OTHER SEX HAIR [EYES THEIGHT WEIGHT BIRTH DATE RACE
CLIS!
PRIOR MECHANICAL. DEFECTS: •I NONE APPARENT [ REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGE AREA INSURANCE CARRIER POLICY NUMBER O UNK. • NONE • MINOR
O MOD. • MAJOR • ROLL-OVER
DIR OF ON STREET OR HIGHWAY [SPEED LIMIT DOT
TRAVEL
TCP/PSC MC/MX
PREPARR'S NAMF DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED Van Horne, S 004274 Yes •NO X NA Brett, R 001525
|01/07/2025
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC COLLISION CODING Page 2 of 4
CHP 555 Page 2 (Rev. 4-11) OPI 060
DATE OF COLLISION (MO. DAY. YEAR)TIME (2400) NCIC # D OFFICER I.D. NUMBER 3315 CITY OF RIA
12/31/2024 2000 004274 24-101416
OWNER'S NAME NOTIFIED
2075 AUG 2 MIERS OORES." E YES • No
PKPEKNBANAGC
DESCRIPTION OF DAMAGE
RECEI
CLERT
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES OCCUPANTS CHILD RESTRAINT 8 - UNKNOWN
A - NONE IN VEHICLE • - IN VEHICLE USED
M. AIR BAG NOT DEPLOYED
B - UNKNOWN R - IN VEHICLE NOT USED
C - LAP BELT USED ) - RADIO / C
D - LAP BELT NOT USED - IN VEHICLE IMPROPER REARE
- IN VEHICLE IMPROPER U: : - SMOKIN
1 • DRIVER E - SHOULDER HARNESS USED U - NONE IN VEHICLE 123 2 TO 6 - PASSENGERS
F - SHOULDER HARNESS NOT USE EETE FROM VEHICL
4 5 6 7 - STATION WAGON REA
1:ARRSONAL HYGIENE
LAP/SHOULDER HARNESS NOT USE
9 - POSITION UNKNOWN J- PASSIVE RESTRAINT USED V - NO X- NO • PARTIALLY EJECTE J- READINC 7 ; 0 - OTHER - PASSIVE RESTRAINT NOY US W- YES Y - YES - UNKNOW K-OTHER - NOT REQUIRE
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE
PRIMARY COLLISION FACTOR MOVEMENT PRECEDING
TRAFFIC CONTROL DEVICES 2 SPECIAL INFORMATION 1 2 3
LIST NUMBER (# OF PARTY AT FAULT COLLISION
VC SECTION VIOLATED A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED B CONTROLS NOT FUNCTIONING• 8 CELL PHONE HANDHELD IN USE x B PROCEEDING STRAIGHT X B OTHER IMPROPER DRIVING: C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD UNSAFE BACKIN X D NO CONTROLS PRESENT/FACTOR* XX D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN* A HFAD-ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN B SIDESWIPE G 32 FT TRAILER COMBO X G BACKING
X C REAR END H SLOWING / STOPPING
WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE I PASSING OTHER VEHICLE
X A CLEAR E HIT OBJECT J CHANGING LANES
B aLOUDY F OVERTURNED K PARKING MANEUVER
C RAINING G VEHICLE PEDESTRIAN L ENTERING TRAFFIC
D SNOWING H OTHER*: MOTHER UNSAFE TURNING
E rOG / VISIBILITY N XING INTO OPPOSING LANE
F OTHER*: MOTOR VEHICLE INVOLVED WITH O PARKED
G WIND A NON- COLLISION P MERGING
LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY
A DAYLIGHT X C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS) R OTHER*:
B DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS)
X C DARK - STREET LIGHTS E PARKED MOTOR VEHICLE A VC SECTIN VIOLATION CITED
D DARK NO STREET LIGHTS F TRAIN
G BICYCLE VC SEPTION VIOLATION CITED
DARK - STREET LIGHTS NO"
UNCTIONING
H ANIMAL: SOBRIETY - DRUG
ROADWAY SURFACE VC SECTION VIGLATION CITED 1 2 3 PHYSICAL XA DRY I FIXED OBJECT:
B WET XX A HAD NOT BEEN DRINKING
C SNOWY - ICY J OTHER OBJECT: E VISION OBSCUREMENT B HBD - UNDER INFLUENCE D SLIPPERY (MUDDY, OILY, ETC.) F INATTENTION: C HBD - NOT UNDER INFLUENCE.* G STOP & GO TRAFFIC D HBD. -IMPAIRMENT UNKNOWN.*
ROADWAY CONDITIONG (MAK 1 TO 2 PENS) H ENTERING / LEAVING RAMP E UNDER DRUG INFLUENCE*
PEDESTRIAN'S ACTIONS
X A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT - PHYSICAL• A HOLeS. bEeP KUlS
B LOOSE MATERIAL ON ROADWAY* CROSSING IN CROSSWA J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY• INTERSECTI DEFECTIVE VEH. EQUIP H NOT APPLICABLE D CONSTRUCTION-REPAIR ZONE K I SLEEPY / FATIGUED*
C AT MIERSECTION SWAK. NOT
LE REDUCED ROADWAY WIDTH
IF FLOODED• D CROSSING - NOT IN CROSSWALK L. UNINVOLVED VEHICLE IG OTHER:" E INROAD - INCLUDES SHOULDER MOTHER:
X H NO UNUSUAL CONDITIONS F NOT IN ROAD xX N NONE APPARENT
G APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE
Miscellaneous
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& "See Attached Sketch"
• "See Attached factual diagram"
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROI
SKETCH
CHP 555 Page 4 (Rev. 4-11) OPI 061
DATE OF COLLISION (MO. DAY. YEAR) TIME (2400) OFFICER I.D. NUMBER
STY OF B
12/31/2024 2000 5:35 004274 24-101416
ALL MEASUREMENTS ARE APRROXIMATE AND NOT TO SCALE UNLESS STATED "EGE
CITY CLERA
V-2
CALIFORNIA AVE
Golden Chopsix
5 Pages via SFTP Thu, 30 Jan 2025 09:20:16 GMT
PREPARED BY ID NUMBER MO DAY YEAR REVIEWERS NAME MO DAY YEAR Van Horne, S 004274 004274 12/31/2024 Brett, R 001525 01/07/2025
DEPTE OMENT OF CALFORNIA HICHWAY PATROL
NCK* CITY OF RIALTO OFFICER I.D.
PAOROLSON NO ON VERA TEARS NUMBER
12/31/2024 3315 : 5: 004274 24-101416
7075 AUG 20 P
FACTS:
NOTIFICATION: I was dispatched to a call of a non-injury collision at 1854 hours.
All times, speeds and measurements in this investigation are approximate.
Measurements were taken by Google Earth, except where otherwise indicated.
SCENE: See diagram.
PHYSICAL EVIDENCE: V-1 and V-2 had collision damage consistent with a rear- end collision.
STATEMENTS:
Party-1 (Baxter, Robert) stated he was reversing from the parking stall and reversed into P-2's vehicle. P-1 stated he did not see P-2 due to the vehicle's window tint.
Party-2 (Lucesrojas, Franklin) stated he was traveling east through the parking lot. P- 2 stated he did not see P-1 reversing and continued to drive through the parking lot.
P-2 stated as he was driving, he felt P-1 collide into the passenger's side of P-2's vehicle.
OPINIONS AND CONCLUSIONS
SUMMARY: P-2 was traveling east through the parking lot when P-1 was started to reverse from the parking stall. P-1 did not see P-2 and reversed into P-2's vehicle.
AREA OF IMPACT: The approximate area of impact was
383' S/SCL of ONTARIO AVE.
59' E/ECL of CALIFORNIA AVE.
CAUSE: Based on the evidence observed and the involved parties' statements, it is my opinion that Party-1 caused the collision by unsafe backing.
RECOMMENDATIONS: None.
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PREPARED BY ID NUMBER MO DAY YEAR REVIEWERS NAME [MO DAY YEAR Van Horne, S 004274 004274 12/31/2024 Brett, R 001525 01/07/2025 Progressive
PO Box 94639
Cleveland, OH 44101
5: 34
2025 / 320
8/8/20251:23:00 PM
Certified Mail certified number 9489 0090 0C
9489 0090 0027 6567 1752 25
CITY OF RIALTO
CITY CLERKS OFFICE
150 S PALM AVE
RIALTO, CA. 92376
PROGRE
US PO 200S