CITY CLERK'S DATE STAMP
CITY OF RIALTO
10 LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2025 SEP 30 AMII: 14
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:
Coast National INsurance Company a/s/o David Lingurar N/A
FULL NAME DATE OF BIRTH
P.O. Box 268994, Ok City, OK 73126
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 Coast National Insurance Company
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
Claim#: 7009124471-1, P.O. Box 268994, Ok City, OK 73126 (if different from home address provided above):
6-24-2025 7:30am
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: TIME: KI 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.
Riverside Ave and Valley, Rialot, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
Insured hit in the rear by City Police Officer David Padilla with plate# 1684112
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.
Following too close. Improper lookout. Failing to reduce speed to avoid accident 26 05 000082 8FBOSLSB31 CF0923P1 26 [4] 000082
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 13,048.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Deductible Amount: $$2500.00
Item/Date: Veh dig payouts Amount: $10,548.00
BOSLSB3
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $13,048.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY OF RIALTO Item/Date: Amount: $
2025 SEP 30
Item/Date:
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: RECEIVED $13,048.00
CITY CLERK
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: ****Insured is atty represented for injury claim**** NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: | 1
DATE: TIME: • АМ ПРМ DATE: TIME: • АМ • РМ
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 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
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS 1 HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS | BELIEVE THEM TO BE TRUI I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. 26 06 000082 8FBOSSB31 CF0923P1 26[4] 000082
SIGNATURE OF CLAIMANT OR AGENT
Jeanette Hlld for Coast National Insurance Company a/s/o David 9-16-2025 TYPE OR PRINT NAME Lingurar DATE
Insurance Company
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) BOSLSB3 RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CÁ 92376
CITY OF RIALTO
441 SEP 30 АНП: 15
TURING BE
966 RECEN
1057 67TУ 245/70817 TIRES, CITY CL
J) AITH 245/7NR)7 TIRES,
1 LAR MADE IN MEXICO 966
VIN
Claim Reference Id • ... 7009124471-1_A6305944
File Name VIN
File Date 06/30/2025
Label VIN
VIN
Note
Photo Location .0 (Lat), 0.0 (LO
Photo Taken By INGURAR. DAV
26 07 000082 8FBOSSB31 CF0923P1 26[4) 000082
CITY OF RIALTO
INS SEP 30 AMI
15 STEP BUYER
6 Odometer
Claim Reference Id 7009124471-1_A6305944
File Name Odometer
File Date 06/30/2025
Label Odometer
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By : LINGURAR, DAVID
26 08 000082 8FBOSLSB31 CF0923P1 2614) 000082
CITY OF RIALTO
CEP 30 AHI: 15
RECEIV
PLANE SE
Vehicle Registration
Claim Reference Id 7009124471-1_A6305944
File Name Vehicle Registration
File Date 06/30/2025
Label Vehicle Registration
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
:LINGURAR, DAVID
26 09 000082 8FBOSLSB31 CF0923P1 26(4) 000082
CITY OF RIALTO
2725 SEP 30 MURIS
Driver's Side Front
Claim Reference Id : 7009124471-1_A6305944
File Name Driver's Side Front
File Date 06/30/2025
Label Driver's Side Front
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
: LINGURAR, DAVID
26 10 000082 8FBOSLSB31 CF0923P1 26 (4) 000082
CIT YAOF
RIALTO
2025 SEP 30 AMIT: 15
Driver's Side Rear
Claim Reference Id : 7009124471-1_A6305944
File Name Driver's Side Rear
File Date 06/30/2025
Label Driver's Side Rear
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By : LINGURAR, DAVID
26 11 0000828FBOSSB31 CF0923P126[4) 000082
R. Long Se
Passenger's Side Rear
Claim Reference Id 7009124471-1_A6305944
File Name Passenger's Side Rear
File Date 06/30/2025
Label Passenger's Side Rear
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By : LINGURAR, DAVID
26 12 000082 8FBOSLSB31 CF0923P1 26(4) 000082
MA CON CITY OF RIALTO
2073 SEP 30 AMIE: 15
RECEIVED
CITY CLERK
Passenger's Side Front
Claim Reference Id : 7009124471-1_A6305944
File Name Passenger's Side Front
File Date 06/30/2025
Label Passenger's Side Front
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By : LINGURAR, DAVID
26 13 000082 8FBOSLSB31 CF0923P1 26[4) 000082
CITY OF RIALTO
10S SEP 30 AMN•15
RECER
CF
Damage - Center
Claim Reference Id 7009124471-1_A6305944
File Name Damage - Center
File Date 06/30/2025
Label Damage - Center
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By : LINGURAR, DAVID
26 14 000082 8FBOSLSB31 CF0923P1 26 (4) 000082
CITY OF RIALTO
1075 SEP 30 ANI: 15
REDER
CLERK:
Damage - Left Angle
Claim Reference Id 7009124471-1_A6305944
File Name Damage - Left Angle
File Date 06/30/2025
Label Damage - Left Angle
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By :: LINGURAR, DAVID
26 15 0000828FBOSS31 CF0923P1 26(4) 000082
CITY OF RIALTO
2015 SEP 30 AM I: 15
ASCEIVED
CITY CLERK
Damage - Right Angle
Claim Reference Id 7009124471-1_A6305944
File Name Damage - Right Angle
File Date 06/30/2025
Label Damage - Right Angle
VIN
Note
Photo Location 0.0 (Lat), 0.0 (Lon)
Photo Taken By I LINGURAR, DAVID
26 16 000082 8FBOSLSB31 CF0923P1 26[4] 000082
Scan or visit verify.add123.com to verify
AutoDataDirect, Inc.
Verification Code: 7PMXM6T
2025 SEP 30 AM||: 15
California Vehicle Record
Retrieved On: Wed July 02, 2025 02:24:18 PM EDT RECEIVED Reference ID: 7009124471-1 CITY CLERK
Registration Data Venicle Dala Title Data
Tag: 58468B4 VIN: Title:
Issue Date: 10/07/2024 Year: 24 Issue Date: 10/10/2024
Exp. Date: 09/30/2025 Make: TOYT Use: Commercial - Used (31) County: RIVERSIDE (33) Model: Tacoma* Odo Read: 14
Plate Type: Regular Commercial Trim: SR* Odo Status: ACTUAL (31) Body: Pickup (PK) Odo Date: 09/20/2024
Reg. Exp. Date: 09/30/2025 Class Code: LL
Weight: 04280
Fuel: Gas (G)
Year First Sold: 24
Number of Axles: 2
Conditions
Date: 10/08/2024 Message: SMOG DUE 09/30/32
Message: NO MAILING ADDRESS
Message: TIP OFC:C54 D:06/30/25 ID/S:5V1201 T:H00
Date: 10/07/2024 Message: PREV LIC P983146
OMM Fees for period 09/30/22024-09/23/2025 Date of Loss: 08/24/2025 Description Amount Prorated Amount
ATD FEE: $1.00 $0.27
TRANSFER FEE: $15.00 $15.00
WEIGHT FEE: $80.00 $21.48
VLF UNUSED PORTION: $67.00 $67.00
ABANDONED VEHICLE ABATEMENT FEE: $1.00 $0.27
ALT FUEL TECH REG FEE: $3.00 $0.81
REG FEE: $71.00 $19.06
AQMD FEE: $7.00 $1.88
SMOG ABATEMENT FEE: $20.00 $5.37
SAFE FEE: $1.00 $0.27
CHP FEE: $32.00 $8.59
TRANSPORTATION IMPROVEMENT FEE: $194.00 $52.09
TRANSFER SMOG FEE: $8.00 $8.00
FINGERPRINT FEE: $2.00 $0.54
Settlement Total to Registered Owner: $200.63
etund DMy Fees for period 09/30/2024 - 09292025
26 17 000082 8FBOLSB31 CF0923P1 26(4] 000082 Company Refund: $47.00 Vehicle Interests
Lessor TOYOTA LEASE TRUST
LINGURAR DAVID EZRAH LSE
6836 RED CARDINAL CT
CORONA, CA 92880
Owner 2 LINGURAR VIOREL
LINGURAR DAVID EZRAH LSE
:
6836 RED CARDINAL CT
CORONA, CA 92880
CITY OF RIALTO
Lienholder TOYOTA MTR CRDT CORP
PO BX 30203 2025 SEP 30 AMII: 15
COLLEGE STA, TX 77842
RECEIVEO
Raw Record Date CITY CLERK
ABANDONED VEHICLE FEE] non-commercial vehicle in any county [$3.00] ABANDONED VEHICLE FEE from county 33 and acouiredbate betseen 32/01/2017 and null [$1.00] ALT FUEL TECH REG FEEl Alternate Fuel Technology Regulation ree: 153.00 [AQMD FEE: rom county 33 and tip 92836 and acquiredDate after 4/30/2005 [$7.30] [ATO FEE] from county33 and is not: CVRA after 12/3/1901 [$1.80 [CARCO_THEFT.FEE) unladen weight is less than 10,901 ibs (50.00] [CHP FEE] 15 not CVRA and acquired after 01/91/2023 ($32.30] [CHP_PENALTY FEE) record is not expired (50.90]
[COUNTY TRANS PROJECT FEE] No County Transport aroject fee in county 33 during 03/39/2024 I$0.00 [FINGERPRINT_ FEE) nONCVRA vehicle from county 33. 9/30/2024 $2.00 [MOTORCYCLE_SAFETY_FEE) vetsele is not a motorcycle [$0.00] [PLATE.INTERCHANGE__SEQUENCE_FEE] vehicle does not have personalized plates ($0. 00) [PLATE_ INTERCHANGE, _PERSONALIZED_PEE] vehicle not have personalized plates ($0.00] [REG FEEl vebicle is registered after 1/1/2022 :$71.001 [REG_FEE_PENALTY: record is not expired (50.06]
[REG_FEE_SURCHARGE) venicle is registered in county 33 ($0. 00] [ROAD IMPROVENENT_FEE] not a zero emission vehicle with a vehicle year on or after 2620 [$9.00] [SAFE FEE] nonCVRA vehicle from county 33 on 10/10/2024 is eligible for fee ($1.00] [SALES TAX] Fron 92880in county
[SALVACE_CERTIFICATE FEE] vehicie is
(SHE ALIEN RATE PEP MEAL CHALET A CO ME iN point 2 cense late Bo. 3) (SPECTALIZED PLATE RENEWAL. [SMOG ABATEMENT FEE) vehicle model is 5 or less years old [$20.00] [TRANSFER_FEE] transfer fee is needed [$15.60]
[TRANSFERSMOG FEE] vehicle is 4 years old or under and uses gasoline [$8.00] [TRANSPORTATION_IMPROVEMENT_FEE] vehicle has class code LL [$194.001 [USE_TAX] vehicle doesn't have use tax {$0.00)
[VLF. PENALTY] fees are not expired ($3.00]
(VLF_REFUND SERVICE FEEJ VIF fee [-$23.003
[WEIGHT_FEE) commercial. vehicke with 2 or less axles with weight of 4280 [$80.00] [WEIGHT_FEE_PENALTY) expiration date after date record pulled [$3.00] (DPPA 6) insurance underwriting, rating, claims and antifraud.
This information is provided by the Califoria Department of Motor Vehicles (CaDMV). Auto Data Direct, Inc. is an authorized provider of real-time Califomnia 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 Recordis database, in real time. The authenticity of these records may be authenticated in real time using the ADD online authorization system.
Personal intormation (including.
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 resold.
Any person who knowingly discloses any information in violation of the Driver Privacy Protection Act (DPPA) may be subject to criminal sanctions and civil flability specified in law for unauthorized use of the data.
* Fleid information provided by Auto Data Direct, Inc.
26 (4) 000082
26 18 000082 8FBOSLSB31 CF0923P1
COAST NATI ONAL INSURANCE COMPANY
BW APD YEA
PO BOX 258806
Oklahoma City, OK 73125 30 AMII:15
Supplement of Record 2 Summary RECELVED
GITY CLERK
Written By: BRAD PHILLIPS, License Number: 2409583, 8/7/2025 2:20:31 PM Adjuster: HATTEY, AMBER, (714) 672-1533 Business
Insured: DAVID LINGURAR Owner Policy #: GO15133976 Claim #: 7009124471-1_A6305944 Type of Loss: OOLL1 - MD Date of Loss: 06/24/2025 07:30 AM Days to Repair: 12 Point of Impact: 06 Rear Deductible: 2500.00
Owner (Insured) : Inspection Location: Appraiser Information: Repair Facility:
DAVID LINGURAR Desk [email protected] Drive Life 4111 Buchanan St
Riverside, CA 92503
VEHI CLE
2024 TOYO Tacoma SR Double Cab Automatic w/5' Bed 4D SHORT 4-2.4L Turbacharged Gasoline Port/Direct I njection Gray VIN: Production Date: 08/2024 Interior Color: Black
License: Odometer: 25332 Exterior Color: Gray
State: CA Condition: Good
TRANSMI SSI ON Intermittent Wipers Auxiliary Audio Connection Coth Seats Automatic Transmission Tilt Wheel Satellite Radio Bucket Seats POWER Cruise Control SAFETY WHEELS
Power Steering Rear Defogger Drivers Side Air Bag Aluminum/ Alloy Wheels Power Brakes Keyless Entry Passenger Air Bag PAINT
Power Windows Message Center Anti-Lock Brakes (4) dear Coat Paint Power Locks Steering Wheel Touch Controls 4 Wheel Disc Brakes OTHER Power Mirrors Telescopic Wheel Traction Control California Emissions Heated Mirrors Backup Camera Stability Control TRUCK
DECOR Remote Starter Front Side Impact Air Bags Rear Step Bumper Dual Mirrors Intelligent Cruise Head/Curtain Air Bags Bedliner Privacy Glass RADIO Communications System Trailer Hitch Console/ Storage AM Radio Hands Free Device Trailering Package Overhead Console FM Radio Xenon or LE.D. Headlamps
CONVENI ENCE Stereo Lane Departure Warning
Air Conditioning Search/Seek SEATS
8FBOSLSB31
19 000082
7/2025 2:20:31 PM 116940 | 1.9.07.03270 Page 1
Claim #: 7009124471-1_A6305944
Workfile ID: 303723e3
Supplement of Record 2 Summary
CITY OF RTALTO
2024 TOYO Tacoma SR Double Cal Automatic w/ 5' Bed 4D SHORT 4-2.4L Turbocharged Gasoline Posk Direg Ini ection Gra SEP 30 AMII: 5
Line Oper Description Part Number Qty BREQEdVED Labor Paint CI PriCeGLERK
1 # S01 For supplements, send to 1
[email protected]
2 COOLING
3 S02 R&l Radiator assy w/o hybrid manual 16400AK020 m Ind. trans
4 AI R CONDI TI ONER & HEATER
5 SO2 R&l Condenser 884A0AK010 m 4.0 M
6 S02 Repl AC Service evacuate & recharge 1 m 1.7 M
7 502 Repl AC Service refrigerant recovery m 0.4 M
8 FRAME
9 S01 Repl LKQ Frame assy Double Cab, 51001AK090 1 5.400.00 S 14.1 Manual trans SR + 20%
NOTE: Orossroads Auto Dismantling Eastvale 951-681-3301 Ref# F7241 10 # S01 R&l Frame mech components 14.2 M
11 # S01 R&l Add for transfer frame wiring 3.0 M
12 EXHAUST SYSTEM
13 S01 R&I Rål exhaust assy rearward of m 1.3 M
manifolds
14 WHEELS
15 501 R&l RT/Front R&l wheel 42611AK011 m 0.1
16 S01 R&l LT/Front R&l wheel 42611AK011 m 0.1
17 S01 R&l RT/Rear R&l wheel 42611AK011 m 0.1
S01 R&l LT/Rear R&l wheel 42611AK011 m 0.1
19 FRONT SUSPENSI ON
20 S01 Repl Bleed brake system four wheel m 1.7 M
21 SEATS & TRACKS
22 S01 R&l RT R&l front seat 0.4
23 S01 R&l LT R&l front seat 0.4
24 501 R&l RT R&l rear seat 0.4
25 S01 R&I LT R&l rear seat 0.4
26 # S01 R&l R&l Carpet 2.0
27 REAR BUMPER
28 Repl Bumper cover w/o blind spot 52057AK010 1 386.48 0.6 Double Cab
29 O/H rear bumper 4.5
30 Repl Bumper 52159AK010 1 283.12 Incl.
31 R&I RT Rear bumper stay w/o blind 52151AK020 Incl.
spol
32 R&l LT Rear bumper stay w/o blind 52152AK020 Incl.
spot
33 R&I RT Extension w/o blind spot 52155AK010 Incl.
34 R&I LT Extension w/o blind spot 52156AK010 Incl.
35 S01 Repl RT Step pad outer 52455AK010 1 65.42 Incl.
7/2025 2:20:31 PM 116940|1.9.07.03270 Page 2
Caim #: 700912447.1-1_A6305944
Workfile ID: 303723e3
Supplement of Record 2 Summary
CITY OF RIALTO
2024 TOYO Tacoma SR Double Cab Automatic w/ 5' Bed 4D SHORT 4-2.4L Turbocharged Gasoline Port/ Direct Ini 2025 SEP 30 AMII: 15 S01 Repl LT Step pad outer
1 31.35 RECEIMED
37 S01 Repl RT Step pad inner 52168AK010
CITY CLECRK
38 S01 Rep!.LT Step pad inner 52167AK010 1 31.35
39 VEHI CLE DI AGNOSTI CS
40 S01 Ror Pre-repair scan m
NOTE: Payable upon completion with scan results printout, invoice/photos at .5M 41 * S01 Por Post-repair scan m
NOTE: Payable upon completion with scan results printout, invoice/photos at.5M Scans and calibrations must be accompanied by in process photos and documentation 42 MI SCELLANEOUS OPERATI ONS
43 # Hazardous Waste Removal 1 4.00 X
44 # S01 Fluids - Brake 1 14.00
45 # S01 Ruids - Antifreeze 1 19.00
46 # S01 Subl 2 Wheel / Thrust Angle Alignment 1 89.95 X 47 # S01 D&R Battery 1 0.3
48 # S02 R&I Drain and replace fluids 1.0 M
SUBTOTALS 6,390.09 50.8 0.0
ESTI MATE TOTALS
Category Basis Rate Cost $
Parts 6,296.14
Body Labor 23.5 hrs @ $ 74.00 /hr 1,739.00
Mechanical Labor 27.3 hrs @ $160.00 /hr 4,368.00
Miscellaneous 93.95
Subtotal 12,497.09
Sales Tax $ 6,296.14 @ 8.7500 % 550.91
Total Cost of Repairs 13,048.00
Deductible 2,500.00
Total Adjustments 2,500.00
Net Cost of Repairs 10,548.00
26 21 000082 8FBOSLSB31 CF0923P1 26 (4) 000082
7/2025 2:20:31 PM 116940 | 1.9.07.03270 Page 3
-
Caim#: 7009124471-1_A6305944
Workfile ID: 303723e3
Supplement of Record 2 Summary
CIIXOFRIALTO
2024 TOYO Tacoma SR Double Cab Automatic w/5' Bed 4D SHORT 4-2.4L Turbacharged Gasoline Port/ Direct Injection e#5 SEP 30 AMII: 15
SUPPLEMENT SUMMARY
CITY CLERK
Line Oper Description Part Number Qty Extended Labor Paint Price $
Added Items
2 COOLING
3 S02 R&l Radiator assy w/o hybrid manual 16400AK020 Ind. trans
4 AIR CONDI TI ONER & HEATER
5 S02 R&l Condenser 884A0AK010 m 4.0 M
6 S02 Repl AC Service evacuate & recharge 1 m 1.7 M
S02 Repl AC Service refrigerant recovery 1 m 0.4 M
48 # S02 R&l Drain and replace fluids 1.0 M
SUBTOTALS 0.00 7.1 0.0
TOTALS SUMMARY
Category Basis Rate Cost$
Parts 0.00
Mechanical Labor 7.1 hrs @ $ 160.00 /hr 1,136.00
Subtotal 1,136.00
Total Supplement Amount 1,136.00
NET COST OF SUPPLEMENT 1,136.00
CUMULATI VE EFFECTS OF SUPPLEMENT(S)
Estimate 2,318.14 LISA HANNABLE
Supplement S01 9,593.86 BRAD PHILLIPS
Supplement S02 1,136.00 BRAD PHILLIPS
Workfile Total: $ 13,048.00
TOTAL ADJUSTMENTS: $ 2,500.00
NET COST OF REPAI RS: $ 10,548.00
26 22 000082 8FBOSLSB31 CF0923P1 26 [4) 000082
7/2025 2:20:31 PM 116940 | 1.9.07.03270 Page 4
Claim # : 7009124471-1_A6305944
Workfile ID: 303723e3
Supplement of Record 2 Summary
2024 TOYO Tacoma SR Double Cab Automatic w 5' Bed 4D SHORT 4-2.AL Turbocharged Gasoline Part/Direct InjectioN 2 SEP 30 AMI: 16 CITY OFRTALTO 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 FALLURE 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 DRI VABLE VEHICLE WITH THE REPAIR FACILITY
BEFORE PARTS ARE AVAILABLE, YOU WILL BE RESPONSIBLE FOR ANY UNNECESSARY RENTAL EXPENSES INCURRED DURING REPAIRS.
THIS IS NOT AN AUTHORIZATION TO REPAIR. After the repairs are authorized by the vehicle owner, this estimate MUST be presented to the repair facility prior to the start of repairs. If this estimate is NOT presented to the repair facility prior to the start of repairs, you may be responsible for any additional expenses.
To expedite the handling of any supplemental damage(s), please contact the APPRAISER listed on the estimate. All supplements must be approved by a claims adjuster or appraiser PRIOR to the completion of the repairs.
CA Vehicle Code 3353: Repair facility cannot charge storage while the vehicle is undergoing teardown.
This estimatel appraisal has been prepared by a licensed appraiser. Where indicated as written by, damage assessed by, repaired by or otherwise. This is known as a digitally signed document or electronic signature and constitutes that the appraiser is the author of this document.
26 23 000082 8FBOSLSB31 CF0923P1 26 [4] 000082
7/2025 2:20:31 PM 116940 | 1.9.07.03270 Page 5
Caim #: 7009124471-1_A6305944
Workfile ID: 303723e3
Supplement of Record 2 Summary
CITY OF RIALTO
2024 TOYO Tacoma SR Double Cab Automatic w/5' Bed 4D SHORT 4-2.4L Turbocharged Gasoline Port/ Direct Injectio 8ZS SEP 30 AM/|: 16
FOR YOUR PROTECTION CALI FORNI A LAW REQUI RES THE FOLLOWING TO APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS FALSE CITY CLERK RECEIVED
OR FRAUDULENT INFORMATI ON TO OBTAIN OR AMEND INSURANCE
COVERAGE OR TO MAKE A CLAI M 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 ABBREVI ATIONS OR SYMBOLS THAT MAY
BE USED TO DESCRI BE WORK TO BE DONE OR PARTS TO BE REPAI RED OR REPLACED:
MOTOR ABBREVI ATI ONS/ SYMBOLS: D= DISCONTINUED PART,
A= APPROXIMATE PRICE. LABOR TYPES: B= BODY LABOR, D= DI AGNOSTIC, E= ELECTRI CAL, F= FRAME, G= GLASS, M= MECHANI CAL, P= PAINT LABOR, S- STRUCTURAL, T= TAXED MI SCELLANEOUS, X= NON TAXED
MI SCELLANEOUS. COC ONE: ADJ- ADJACENT, ALGN= ALIGN,
A/M= AFTERMARKET, BLND= BLEND, CAPA= CERTIFIED AUTOMOTIVE PARTS ASSOCIATION, D&R= DI SCONNECT AND RECONNECT,
EST= ESTIMATE, EXT. PRICE- UNI T PRICE MULTI PLI ED BY THE QUANTITY, INCL = INCLUDED, MI SC= MI SCELLANEOUS, NAGS- NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ= NON ADJACENT, O/H= OVERHAUL,
OP= OPERATION, NO= LINE NUMBER, QTY= QUANTITY,
RECOND= RECONDI TION, REFN= REFINI SH, REPL= REPLACE, R&I = REMOVE AND INSTALL, R&R= REMOVE AND REPLACE, RPR= REPAIR, RT= RIGHT, SECT= SECTION, SUBL= SUBLET, LT= LEFT, W/O= WI THOUT, W/_= WITH/_.
SYMBOLS: #= MANUAL LINE ENTRY, * = OTHER [IE..MOTORS DATABASE INFORMATION WAS CHANGED], ** = DATABASE LINE WITH AFTERMARKET, N= NOTES ATTACHED TO LINE. OPT OEM= ORI GINAL EQUI PMENT
MANUFACTURER PARTS EI THER OPTI ONALLY SOURCED OR OTHERWI SE PROVI DED WITH SOME UNI QUE PRI CING OR DI SCOUNT.
''''CURE TIME'' MEANS THE LENGTH OF TIME THAT, PER THE ADHESI VE
MANUFACTURER, THE WINDSHI ELD ADHESI VE NEEDS TO CURE UNTIL THE
WINDSHI ELD CAN PROPERLY FUNCTI ON AS A SAFETY DEVI CE PURSUANT
TO THE FEDERAL MOTOR VEHI CLE SAFETY STANDARDS AND THE
VEHI CLE MANUFACTURER'S SPECI FI CATI ONS.
26 (4)000082
CF0923P1
8FBOSL
000082
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7/2025 2:20:31 PM 116940 | 1.9.07.03270 Page 6
Claim. #: 7009124471-1_A6305944
Workfile ID: 303723e3
Supplement of Record 2 Summary
EITY OF RIALTO
Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Urlds third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are marfitatukade or for the Otherwise noted, (a) all items are derived from the Guide ARM8502, COC Data Date 08/01/285 Calypetentially other 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. Fpr= 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 COC Intelligent Solutions Inc.
The following is a list of abbreviations that may be used in COC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE:
26 25 0000828FB0SLSB31CF0923P126 0923126[4) 000082 BAR= Bureau of Automotive Repair. EPA= Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR= Paintless Dent Repair. VIN= Vehicle Identification Number. 7/2025 2:20:31 PM 116940 | 1.9.07.03270 Page 7
Claim #: 7009124471-1_A6305944
Workfile ID: 303723e3
Supplement of Record 2 Summary
2024 TOYO Tacoma SR Double Cab Automatic w/5' Bed 4D SHORT 4-2.4L Turbocharged Gasoline Port/ Direct Injection Gray CITY OF RIALTO Fraud Language: For your protection California law requires the following to appear on this form:
ayment of a loss is guilty of a crime and may be subiect to tines and confinement in state prisone TY CLI
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.
26 26 000082 8FBOSLSB31 CF0923P1 [4] 000082
7/2025 2:20:31 PM 116940 | 1.9.07.03270 Page 8
26 01 000082 8FB0SLSB31 CF0923P1 26 [4] 000082
EAS SATE
BRISTOL WEST
Part of the Farmers Insurance Group'
September 23, 202)
National Document Center
CITY OF RIALTO P.O. Box 258806
2025 SEP 30 AMI|: 14 RECEIVED
CITY CLERK Oklahoma City, OK 73125-8806
000082
SELF INSURED
150 S PALM AVE
RIALTO CA 92376
CITY OF RIALTO
BRISTOL WEST
INSURANCE GROUP
Fax: (855) 822-3139
09/22/2025
City Of Rialto-City Clerk
150 S Palm Ave
Rialto, CA 92376
Our Insured: David Lingurar
Our Claim #: 099 SUB 7009124471-1
Date of Loss: 06/24/2025
Your Insured: Rialto Police Department
Your Claim #:
Deductible Amount: $2,500.00
Total Amount Owed: $13,048.00
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 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 $13,048.00.
Our theory of liability is as follows: On 6-24-2025 at appx 7:30am at Riverside Ave and Valley, Rialto, CA, Insured hit in rear by City Police Officer David Padilla, Platett of police veh 1684112 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 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 [4] 000082 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 :000082 8FBOSLSB31 CF0923P1 send payment to:
National Document Center
PO Box 268992
Oklahoma City, Ok 73126
Thank you,
BOSLSB3
Jeanette Hild
Litigation Claims Representative
Coast National Insurance Company CITY OF RIALTO
616-803-7667 (Call/Text)
2025 SEP 30 AMII: 14
CITY CLERK RECEIVED
26 03 0000828F0SS31 CF0923P126 [4] 000082
carmers s
700012472-11s Search Address Book CEP REPORT PHISHING
CITY OF RIALTO
Claim: 7009124473-1 Ins DAVID LINGURAR Dot: 06/24/2025 Loss Stote: SER 302 le Co: 0
CITY CLERK RECEIVED
i (Total Incurred: $10,548.00): Checks :
Pay to.- dross Amount s taste Date Someda ded Send Date Status Invoice N David Lingurar and Drive S0.212:00 07/29/2025 :07/20/2025 Cleared Life LLC
Dric Life LLC incid 08/01205 08/07/2025 Cleaned
26 04 000082 8FB0SLSB31CF0923P126 CF0923P126(4] 000082
BOSLSB3