CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2025 SEP 17 AMII: 31
NIA CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
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 5911.2).
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:
Veronica S. Harris DATE OF BIRTH
FULL NAME
HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
VIA )
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
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: 08-26-25 TIME: 10:40 amAMOPM
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.
Where strate, oud oN San BerNardiNo Ave a I dyllwild
3. HOW DID DAMAGE OR INJURY OCCUR?
while driviNg WB oN San berNardino Hue my driverside
tront tire hita pothole at tullspeed at intersection
with Idyllwild. Incident reported to City of Rialto.
4. WERE POLICE AT THE SCENE? • YES • NO WERE PARAMEDICS AT THE SCENE? DYES • 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.
Large pothole in street. Reported to City of Rialto.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,825,81 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Eront Bumper 110-26-25 Amount: $
Amount: $.
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $1825, 18 81 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Rental car Asdays Amount: $ 230,0°
Item/Date: UNKNOwN damage Amount: $ UNk
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
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: L 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A
NAME:
ADDRESS: ADDRESS: —
TELEPHONE: ) TELEPHONE: L)
DATE: TIME:
DATE: TIME: DAMO 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. to venice enter eatin the Town vehicle when you first saw it, and by "B° location of yourself or your vehic hen 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 th 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.
I dyllwitore
PARKWAY
SaN Bernardi SIDEWALK
3 ^ % I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Veronica Harris 09/16/25
TYPE OR PRINT NAME DATE
Self
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 CALIBER - RIALTO Workfile ID: 24402dcc
CALIBER Federal ID: 33-0730794
CALIBER COLLISION CENTERS State ID: 33-0730794
Federal EPA: N/A
RESTORING THE RHYTHM OF YOUR LIFE State EPA: CAL000265317 • COLLISION 421 West Rialto Avenue, RIALTO, CA 92376 BAR: ARD299767 Phone: (909) 874-4470
FAX: (909) 874-4561
Preliminary Estimate
Customer: Harris, Ron
Written By: Saul Alcaraz
Insured: Harris, Ron Policy #: Claim #:
Type of Loss: Date of Loss: Days to Repair: 5
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
Harris, Ron CALIBER - RIALTO CUSTOMER PAY
421 West Rialto Avenue
RIALTO, CA 92376
Repair Facility
(909) 874-4470 Business
VEHICLE
2012 TOYO Camry Hybrid LE 4D SED 4-2.5L Hybrid - TBD - Magnetic Gray Metall VIN: Interior Color: Light Gray Mileage In: 179,151 Vehicle Out:
License: Exterior Color: Magnetic Gray Metall Mileage Out:
State: CA Production Date: 12/2011 Condition: Job #:
TRANSMISSION Air Conditioning Search/Seek Bucket Seats
Automatic Transmission Intermittent Wipers CD Player WHEELS POWER Tilt Wheel Auxiliary Audio Connection Wheel Covers Power Steering Cruise Control SAFETY PAINT
Power Brakes Rear Defogger Drivers Side Air Bag Clear Coat Paint Power Windows Keyless Entry Passenger Air Bag Metallic Paint Power Locks Message Center Anti-Lock Brakes (4) OTHER
Power Mirrors Steering Wheel Touch Controls 4 Wheel Disc Brakes Traction Control DECOR Telescopic Wheel Front Side Impact Air Bags Stability Control Dual Mirrors Climate Control Head/Curtain Air Bags California Emissions Tinted Glass RADIO Hands Free Device Power Trunk/Liftgate Console/Storage AM Radio Rear Side Impact Air Bags
Overhead Console FM Radio SEATS
CONVENIENCE Stereo Cloth Seats
9/9/2025 1:53:36 PM 036535 Page 1
•
Preliminary Estimate
Customer: Harris, Ron
2012 TOYO Camry Hybrid LE 4D SED 4-2.5L Hybrid - TBD - Magnetic Gray Metall Line Oper Description Part Number Qty Extended Labor Paint Price $
1 # ** preliminary estimate subjet to 1
change upon teardown **
# ** part prices may change upon 1
vender price updates**
#
4 #
5 FRONT BUMPER & GRILLE
6 O/H front bumper 2.4
< Repl Bumper cover 5211906974 1 313.13 Incl. 2.6
8 Add for Clear Coat 1.0
9 * R&I RT Hole cover LE model Incl
10 * R&I LT Hole cover LE model Incle
11 Repl Lower grille 5311206200 1 75.83 Incl.
12 Repl RT Bumper cover fastener 9046705090B1 1 2.79
13 Repl RT Bumper cover retainer plate 5387906100 1 10.03 14 R&I License bracket 0.2
15 R&J R&i grille assy Inct.
16 RADIATOR SUPPORT
17 Repl RT Under cover 5144106150 1 99.29 0.2
18 Repl LT Under cover 5144206140 1 128.56 0.2
19 Repl Under cover clip 9046707214 5 9.20
VEHICLE DIAGNOSTICS
21 # Pre-repair scan 1 40.00 X 0.5
22 # Post-repair scan 1 80.00X 0.5
23 # Refn Color Tint 0.5
24 # Subl Hazardous Waste Disposal 1 500X
SUBTOTALS 763.83 4.0 4.1
9/9/2025 1:53:36 PM 036535 Page 2
•
Preliminary Estimate
Customer: Harris, Ron
2012 TOYO Camry Hybrid LE 4D SED 4-2.5L Hybrid - TBD - Magnetic Gray Metall
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 638.83
Body Labor 4.0 hrs @ $ 89.00 /hr 356.00
Paint Labor 4.1 hrs @ $ 89.00 /hr 364.90
Paint Supplies 4.1 hrs @ $ 66.00 /hr 270.60
Miscellaneous 125.00
Subtotal 1,755.33
Sales Tax $ 909.43 @ 7.7500% 70.48
Grand Total 1,825.81
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,825.81
==================== =======
---
Caliber Collision is the industry leader in quality collision repair. Since day one, our highest purpose has been to get people just like you back on the road as quickly as possible and fully restored to the rhythm of your life. You can be sure we do everything possible to ensure your complete satisfaction including:
Personalized, high quality service from the largest collision repair company in the U.S.
Consistently ranked among the highest customer satisfaction scores in the industry.
Approved by every major insurance company in the U.S.
Expedited car rental and towing services to get you back on the road again in no time.
Repair work backed by a written, lifetime warranty honored at every location. 24/7/365 customer service to answer questions and put your mind at ease.
This is a preliminary estimate based on visible damage. There may be additional repairs needed once the vehicle is taken apart by our I-CAR Gold Class technicians to identify any additional damage.
If an insurance company has written an estimate for you, please provide us with a copy. Properly endorsed insurance company checks are welcome as payment for the repair of your vehicle. Caliber Collision gladly accepts all major credit cards, debit cards, cashier's and traveler's checks. See your Caliber Collision center for details on acceptance of personal checks.
Before leaving your vehicle with us, please remove all important personal and valuable items from your vehicle.
Caliber Collision is not responsible for belongings left in your vehicle.
Please let us know how we can be of further assistance, and when we can schedule an appointment for your vehicle to be repaired.
Caliber Collision - Restoring The Rhythm Of Your Life
= ========= =====**=*=========== ====== ---
9/9/2025 1:53:36 PM 036535 Page 3
Preliminary Estimate
Customer: Harris, Ron
2012 TOYO Camry Hybrid LE 4D SED 4-2.5L Hybrid - TBD - Magnetic Gray Metall
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.
9/9/2025 1:53:36 PM 036535 Page 4
Preliminary Estimate
Customer: Harris, Ron
2012 TOYO Camry Hybrid LE 4D SED 4-2.5L Hybrid - TBD - Magnetic Gray Metall 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 ARM8525, CCC Data Date 08/15/2025, 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.
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. Aign.=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. 9/9/2025 1:53:36 PM 036535 Page 5
.".'
Islas Auto Body Estimate ID
300 S Sycamore Ave Building B, Rialto, CA 92376-6579 24677501 Original
ESTE Office: (951) 904-0479
AUTO BODY [email protected]
islasautobody.com
Owner Appraiser
VERONICA HARRIS Julio Islas
[email protected]
Classification
None
Loss Type Deductible
Unknown Unknown
2012 Toyota Camry Hybrid LE 4 Door Sedan 2.5L4 Cyl Hybrid Injected Auto Trans FWD VIN Drivable Mitchell Service Code
Unknown
Options
Air Conditioning AM-FM Stereo Anti-Lock Brake Sys. (ABS) Auto Air Condition Automatic Headlights Auxiliary Input Bluetooth Wireless CD Player Cloth Seat Cruise Control Connectivity
Daytime Running Lights Driver-Front Air Bag Dual A/C Electric Defogger Electronic Stability Control First Row Bucket Seat 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 Remote Decklid Or Tailgate Second Row Side Airbag With Side Airbags Smart Key System Steering Wheel Mounted Release Head Protection Audio Control
Tilt Steering Wheel Tire Pressure Monitoring Traction Control/Electronic Trip Computer System
VERONICA HARRIS | 2012 Toyota Camry Hybrid LE
Parts Profile Parts Profile Version
AM and QR Parts
LABOR PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax Front Bumper.
100384 Frt Lwr Bumper Cover Remove Body 0.4# 0.4 New 53112-06200 1 $75.83 Yes Grille / Replace
AUTO Frt Bumper Cover Remove Body 1.3# 1.3
/ Install
Front Inner Structure
3 101885 Frt Body Front Remove Body 2.5 2.5 New 57104-07022 1 $426.63 Yes Crossmember-s / Replace
4 AUTO Frt Rad Supt Refinish Refinish 0.8 0.8
Crossmember Only
Engine / Body Under Covers.
Committed On Version Mitchell Cloud Estimating™ Printed On Profile Page 1 of 3 Mitchell Estimating 25: Copyright 1994-2025 Mitchell International, Inc 8/26/2025 System profile DEM AUG 25_V 04:31 PM Protile Version
All Rights Reserved 10.0
• • '
LABOR PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax 100526 REngine Under Cover Remove Body 0.3 0.3 New 51441-06150 1 $99.29 Yes / Replace
100527 L Engine Under Cover Remove Body 0.3 0.3 New 51442-06140 1 $128.56 Yes / Replace
100530 R Frt Engine Under Cover Remove Body 0.4 0.4 New 58167-06020 1 $161.39 Yes / Replace
8 100531 L Frt Engine Under Cover Remove Body 0.4 0.4 New 58168-06010 1 $160.93 Yes / Replace
Additional Costs & Materials
9 AUTO Paint/Materials Additional $36.00 Yes
Cost
10 AUTO Shop Materials Additional $5.00* Yes
Cost
11 AUTO Hazardous Waste Additional $4.00* Yes
Disposal Cost
Special / Manual Entry..
12 900500 AC PENDING REVIEW Remove Body" 0.0° 0.0 New 1 $0.00° Yes FOR DAMAGES / Replace
13 900500 LIFT UP VEHICLE Remove Body* 1.0% 0.0 New 1 $0.00* Yes / Replace
*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 I Very hear are and propretering.
d Discontinued by Manufacturer
Estimate Totals
Labor Units Rate Sublet Add'| Amount Totals
Body Labor 6.6 $75.00 $495.00
Refinish Labor 0.8 $65.00 $52.00
Total Labor 7.4 $547.00
Taxable $547.00
Tax 0.0000% $0.00
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Labor Total $547.00
Parts Amount
Taxable Parts $1,052.63 $1,052.63
Parts Adjustments $0.00
Tax 7.7500% $81.58
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Parts Total $1,134.21
Costs Amount
Paint Materials $36.00 $36.00
Shop Materials $5.00 $5.00
Other Additional $4.00 $4.00
Costs
Committed On Mitchell Cloud Estimating™ Printed On Profile Page 2 of 3 Mitchel Estimating 252 8/26/2025 System profile
opyright 1994-2025 Mitchell International, Inc Profile Version OEM AUG 25 V All Rights Reserved 04:31 PM
10.0 Estimate Totals
Paint Materials: Taxable $45.00
- Refinish Units: O.8 units Tax 7.7500% $3.49
- Rate: $45.00 Non-Taxable $0.00
- Rate Max: 99.9 units Pre-Tax Discount 0.00% $0.00
- Additional Rate: $0.00 Costs Total $48.49
Shop Materials:
- Rate: $5.00
Gross Totals Amount
Gross Total $1,729.70 $1,729.70
Taxable $1,644.63
Tax $85.07
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Gross Total $1,729.70
Adjustments Amount
Total Customer $0.00
Responsibility
Net Estimate Total $1,729.70
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.
Estimate Event Log
Job Created 8/26/2025 04:26 PM
Estimate Started 8/26/2025 04:28 PM
Estimate Printed 8/26/2025 04:31 PM
Estimate Committed Estimate Not Committed
Estimate Retrieval ID 1007390792
Committed On Version Mitchell Cloud Estimating™M Printed On Profile Page 3 of 3 Mitchell Estimating 25.2 Copyright 1994-2025 Mitchell International, Inc. 8/26/2025 System profile 04:31 PM Profile Version
All Rights Reserved 10.0